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Full text of "Human paleopathology : current syntheses and future options"

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Human Paleopathology 



Current Syntheses 

and 
Future Options 



J 






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Human Paleopathology 



Current Syntheses 

and 
Future Options 



Edited by 
Donald J. Ortner 

and 
Arthur C. Aufderheide 



A Symposium held at the International Congress of 
Anthropological and Ethnological Sciences 
Zagreb, Yugoslavia, 24—31 July 1988 



Smithsonian Institution Press 
Washington and London 






Copyright © 1991 by the Smithsonian Institution. 

All rights are reserved. 

This booic was edited and designed by Nancy P. Dutro. 

Library of Congress Cataloging-in-Publication Data 

Human paleopathology ; current syntheses and future options / 
edited by Donald J. Ortner and Arthur C. Aufderheide. 
p. cm. 

Based on a symposium held during the International 
Congress of Anthropological and Ethnological Sciences, 
Zagreb. Yugoslavia, July 24-31, 1988. 

Includes bibliographical references and index. 

ISBN 1-56098-039-7 

I. Paleopathology — Congresses. I. Ortner, Donald J. 
II. Aufderheide, Arthur C. III. International Congress of 
Anthropological and Ethnological Sciences ( 12th : 1988 : 
Zagreb, Croatia) 

(DNLM: I. Paleopathology — congresses. QZ 11.5 H9I8 

1988] 
R1.34.8.H86 1991 
616.07— dc20 
DNLM/DLC 
for Library of Congress 90-10348 

British Library Cataloguing-in-Publication Data is available. 

©The paper used in this publication meets the minimum 
requirements of the American National Standard for Permanence 
of Paper for Printed Library Materials Z39.48-1984. 

Printed in the United States of America. 
5 4 3 2 1 
94 93 92 91 90 

For permission to reproduce individual illustrations appearing in 
this book, please correspond directly with the owners of the 
images, as stated in the picture captions. The Smithsonian 
Institution Press does not retain reproduction rights for these 
illustrations individually or maintain a file of addresses for photo 
sources. 




Preface 



In 1985 Dr. PavaoRudanaskedoneof us (DJO) to organize a 
symposium on paleopathology for the International Congress 
of Anthropological and Ethnological Sciences, planned for 
July 1988 in Zagreb, Yugoslavia. This invitation was intrigu- 
ing for many reasons but principally because we felt that 
research in paleopathology had reached a plateau. In our 
opinion the time had arrived to evaluate research conducted 
thus far as a basis for suggesting what needed to be done to 
continue the development of research in the discipline. 

In 1985 initial invitations for papers for the symposium 
went out to a large and diverse group of leading scholars in 
paleopathology. The response was remarkably supportive 
and definite plans were made. 

A commensal scholarly/scientific relationship in paleopa- 
thology between anthropologically and medically trained re- 
searchers has existed for many decades. It clearly was in the 
interest of good science to have both these disciplines in- 
volved in planning the symposium. Arthur C. Aufderhcide, 
M.D., a medically trained pathologist, became coorganizer 
of the symposium and coeditorof the proceedings in the early 
stages of planning. Donald J. Ortner, Ph.D., a physical an- 
thropologist, provided the anthropological perspective in the 
organization and editorial process. 

Objectives for the symposium included; ( I ) review of the 
current status of research in paleopathology, (2) an effort to 
explore what can and cannot presently be said about paleopa- 
thology, (3) the contributions of paleopathology to our under- 
standing of the history and evolution of disease, (4) an eflbrt 
to explore the possibility of paleoepidemiology, (5) an at- 
tempt to establish criteria that would permit comparative 
research in paleopathology, (6) an effort to establish the an- 
tiquity of modem diseases, (7) an exploration of what paleo- 
pathology could contribute in an ideal research context. (8) 
ways to achieve the above objective, and (9) the directions 
research in paleopathology could take in the future. 

There are four major subject areas in paleopathology: ( 1 ) 
soft tissue research generally conducted by medically trained 
scientists, (2) skeletal tissue research more often conducted 
by anthropologists, (3) analysis of historical and archeologi- 
cal materials in which medical historians are the major schol- 
ars, and (4) biochemical research on trace elements and more 
recently on DNA and immunoglobulins generally conducted 
by biochemists or medically trained scientists. 

The organizers attempted to have a significant representa- 
tion of papers in each of these general research areas. We 

Zagreb Palt'opalhology Symp. 1988 



achieved only partial success. We did get a good group of 
papers on theory and methodology, another group on skeletal 
paleopathology, and a fairly substantial cluster of papers on 
soft-tissue and biochemical research. We were less success- 
ful in stimulating papers on the use of archeological and 
historical materials in research on paleopathology. This par- 
tially reflects the inadequate efforts by paleopathologists to 
create scholarly networks and linkages with the historians of 
disease and medicine. This clearly is a problem that needs to 
be corrected. 

Given the international nature of the Congress we also 
stressed the need to have scholars from many countries. 
Clearly the research interests and focus vary .somewhat in 
different nations. It is equally true that writing a scientific 
paper in a language other than one's native tongue may place 
colleagues from other than English-speaking countries in a 
difficult position. We felt, however, that the rewards of inter- 
national scholarship outweighed the problems inherent in 
writing in another language. 

The coeditors have rewritten portions of some of the manu- 
scripts in an attempt to convey more effectively our under- 
standing of what the author was attempting to communicate. 
The pressures of deadlines and our wish to expedite publica- 
tion made author review of our revisions impossible. We take 
full responsibility for any failures to accurately reflect the 
original meaning of the author. 

Not all participants were able to complete manuscripts for 
the proceedings. Svante Paabo told us in advance that be- 
cause of other commitments he would be unable to prepare a 
formal manuscript. He gave a verbal presentation during the 
symposium and participated actively in the discussions. Sara 
Bisel was unable to complete the revision of her manuscript 
due to a very serious illness. Because of this the coeditors felt 
that it would be inappropriate to publish her paper. 

The coeditors would like to acknowledge the assistance of 
Agnes 1. Stix and Janet T. Beck, Department of Anthropol- 
ogy, National Museum of Natural History, Smithsonian In- 
stitution, who have provided editorial, administrative, and 
logistical support throughout the planning and editorial 
phases of this scholarly endeavor. Marcia Bakry, also of the 
Smithsonian Department of Anthropology, improved many 
of the illustrations. Sara Hammer, Paleobiology Laboratory, 
University of Minnesota-Duluth School of Medicine, also 
contributed significantly to the completion of the editorial 
process. 

V 



Contents 



1 Donald J. Ortner and Arthur C. 
Aufderheide; Introduction 

THEORY 

5 Donald J. Ortnf.r: Theoretical and methodological 
issues in paleopathology 

12 Susan Pfeiffer: Is paleopathology a relevant 
predictor of contemporary health patterns? 

18 Don R. Brothwell: On zoonoses and their 
relevance to paleopathology 

23 Keith Manchester: Tuberculosis and leprosy: 
Evidence for interaction of disease 

36 Patty Stuart-Macadam: Porotic hyperostosis: 
Changing interpretations 

40 Ann Stirland: Diagnosis of occupationally related 
paleopathology: Can it be done? 

METHODS 

5 1 Noreen Tuross: Recovery of bone and serum 

proteins from human skeletal tissue: IgG, osteonectin, 
and albumin 

55 Debra L. Martin: Bone histology and 

paleopathology: Methodological considerations 

60 William W. Hauswirth, Cynthia D. Dickel, 
Glen H. Doran, Philip J. Laipis and David N. 
Dickel: 8000-year-old brain tissue from the 
Windover site: Anatomical, cellular, and molecular 
analysis 

73 Antonio Ascenzi, A. Bellelli, M. Brunori, G. 
CiTRo, R. Ippoi iTi, E. Lendaro and R. Zito: 
■ Diagnosis of thalassemia in ancient bones: Problems 
and prospects in pathology 

76 U.E.C. Confalonieri, L.F. Ferreira, A.J.G. 
Araujo, M. Chame, and B.M. Ribeiro 
FiLHO: Trends and perspectives in 
paleoparasitological research 



79 Arthur C. Aufderheide and Mary L. 
Aufderheide: Taphonomy of spontaneous 
("natural") mummification with applications to the 
mummies of Venzone, Italy 

87 C.-A. Baud and Christiane Kramar: Soft tissue 
calcifications in paleopathology 

90 Peter K. Lewin: Technological innovations and 
discoveries in the investigation of ancient preserved 
man 

92 LuBOS Vyhnanek and Milan Stloukal: Harris' 
lines in adults: An open problem 

95 Oscar Urteaga-Ballon: Medical ceramic 

representation of nasal leishmaniasis and surgical 
amputation in ancient Peruvian civilization 

POPULATION STUDIES 

105 Douglas W. Owsley: Temporal variation in 

femoral cortical thickness of North American Plains 
Indians 

1 1 1 Marc A. Kelley: Ethnohistorical accounts as a 

method of assessing health, disease, and population 
decline among Native Americans 

1 19 Jerome C. Rose and Philip Hartnady: 

Interpretation of infectious skeletal lesions from a 
historic Afro-American cemetery 

128 Takao Suzuki: Paleopathological study on 
infectious diseases in Japan 

140 PiA Bennike: Epidemiological aspects of 

paleopathology in Denmark: Past, present, and 
future studies 

145 Juan R. Munizaga: Human skeletal pathology in 
pre-Columbian populations of northern Chile 

151 Miroslav Prokopec and Graeme L. Pretty: 
Observations on health, genetics, and culture from 
analysis of skeletal remains from Roonka, South 
Australia 



Zannrb Paleopathology Symp. i98S 



Vll 



viii • Contents 



TUBERCULOSIS 

161 Jane E. Buikstra and Sloan Williams: 

Tuberculosis in the Americas: Current perspectives 

173 Mary Lucas Powell: Endemic treponematosis and 
tuberculosis in the prehistoric southeastern United 
States: Biological costs of chronic endemic disease 

181 Eugen Strouhal: Vertebral tuberculosis in ancient 
Egypt and Nubia 



TUMORS 

251 JuDYTA Gladykowska-Rzeczycka: Tumors in 
antiquity in East and Middle Europe 

257 Enrique Gerszten and Marvin J. Allison; 
Human soft tissue tumors in paleopathology 

261 James M. Tenney: Identification and study of 
carcinoma in paleopathoiogical material: Present 
status and future directions 



LEPROSY 

197 Joseph Zias: Leprosy and tuberculosis in the 
Byzantine monasteries of the Judean Desert 

200 Debra a. Chase: Evidence of disease in ancient 
Near Eastern texts: Leprosy in the Epilogue to the 
Code of Hammurapi? 

205 JoHS G. Andersen: The medieval diagnosis of 
leprosy 



DENTAL DISEASE 

269 Albert A. Dahlberg: Interpretations of general 
problems in ameiogenesis 

273 Gabor Kocsis and Antonia Marcsik: Two 

developmental anomalies of the teeth and resulting 
secondary pathosis 

280 Alan H. Goodman: Stress, adaptation, and enamel 
developmental defects 



ARTHRITIS 

21 1 James C.C. Leisen, Howard Duncan, and J.M. 
Riddle: Rheumatoid erosive arthropathy as seen in 
macerated (dry) bone specimens 

216 Jan Dequeker: Paleopathology of rheumatism in 
paintings 

TRAUMA 

225 Charlotte Roberts: Trauma and treatment in the 
British Isles in the Historic Period: A design for 
multidisciplinary research 

241 Robert D. Jurmain: Paleoepidemiology of trauma 
in a prehistoric central California population 



MISCELLANEOUS CONDITIONS 

291 James Blackman, Marvin J. Allison, Arthur 
C. Aufderheide, Norman Oldroyd, and R. Ted 
Steinbock: Secondary hyperparathyroidism in an 
Andean mummy 

297 Wolfgang M. Pahl and W. Undeutsch: 

Noma — cancer aquaticus: First indication of the skin 
involving disease in ancient Egypt? 



305 Arthur C. Aufderheide and Donald J. Ortner: 
Synthesis and conclusions 



309 Participants 



Introduction 



Donald J. Ortner and Arthur C. Aufderheide 



What scientific generalizations about paleopathology can 
now be made'.' What can paleopathology tell us about biolog- 
ical processes in the past? To what extent does current medi- 
cal knowledge relate to the interpretation of paleopathologi- 
cal specimens? These and many more questions are of critical 
importance to the status of current and future research in 
paleopathology. We need to give careful thought to more 
general and longer-range goals for paleopathology and the 
need to integrate that research into the broader context of 
biomedical theory. These considerations will be among the 
major factors that will determine the nature and quality of 
research in the future. 

Clearly our descriptive methodology and classificatory 
system are currently major barriers to comparative research. 
In many published reports it is virtually impossible to evalu- 
ate the evidence presented because the descriptions are vague 
and imprecise. Worse still, some authors provide a medically 
based diagnostic opinion with insufficient data to permit in- 
dependent evaluation. 

The coeditors of this volume suggest that at least some 
aspects of paleopathological research have reached a plateau 
beyond which significant further progress cannot be made 
without major changes in the type of research we do and the 
methods we use to do it. Any effort, for example, to find 
general trends in the history and evolution of disease on the 
basis of existing published reports on paleopathology imme- 
diately confronts serious problems in the lack of com- 
parability of source materials. We must develop at least gen- 
eral guidelines for the basic data needed and the methodology 
necessary to build a base of data that will permit research on 
some of the important questions we need to address. 

In our opinion paleopathology has reached the point where 
we can at least begin to evaluate the potential of various 
avenues of research and begin to suggest methodological 
options for achieving these objectives Rapidly developing 
biomedical technology is beginning to offer some potentially 
powerful research tools for paleopathology. Trace element 
and isotopic analysis have already clarified important dietary 
and nutritional factors in human archeological populations. 
The recovery of DNA from archeological human tissues may 

Zagreb Paleopaihology Symp. J 988 



provide important data on diseases that have a genetic basis. 
The recovery of human IgG from archeological bone tissue, 
reported in this volume by Noreen Tuross, offers the potential 
of identifying infectious diseases that were present in a popu- 
lation. This is possible even if individuals in the living popu- 
lation were only exposed to the disease organisms and did not 
have the disease itself. 

The application of high-tech biochemical methods to prob- 
lems in paleopathology involves many methodological haz- 
ards that are poorly understood. Postmortem diagenic change 
is a major barrier in such research. Little is known about the 
f)otential of false positives or negatives resulting from di- 
agenic processes or contamination of biological tissues by 
natural products in the soil environment. We also need to 
know more about the biology of the tissues we use in this 
research. For example, are there age-related differences in 
the biochemistry and histology of normal bone tissue? These 
problems clearly deserve more attention than is apparent in 
some of the current publications. The well-known problems 
that have emerged with trace element research in archeologi- 
cal bone tissue provide a good case study regarding the haz- 
ards associated with the simplistic application of biochemical 
methods to such materials. 

Another issue in paleopathology is that inadequate atten- 
tion has been given to theory. There have been some impor- 
tant attempts to explore theoretical aspects of both the time 
and space dimensions of disease in antiquity (e.g. , Cockbum 
1963; McNeill 1976; Grmek 1989). However, much of this 
emphasis has been in the scholarly context of medical history 
and very little attempt has been made to interpret paleopa- 
thological data in the general context of biological and medi- 
cal theory. An exception to this is the recent book by Grmek 
( 1989). There are interesting and important theoretical ques- 
tions that must be explored as wc begin to integrate research 
in paleopathology with the b(xJy of theory and data in other 
disciplines. 

Perhaps the most urgent need in paleopathology is a care- 
ful review of the methods wc are using. Methodology helps 
us to respond to the question of "what is it'" when we see a 
pathological condition. Certainly describing and, if possible, 

I 



2 • Introduction 



classifying what we observe are important. However, this 
objective must be achieved within the framework of princi- 
ples of descriptive and classificatory rigor that are well 
known and established in other biological and medical disci- 
plines. 

We must also move beyond description and classification 
and ask "what does it mean?" In the context of this question, 
theory, including both medical and biological, is critical. 
Theoretical questions in paleopathology abound and are 
largely unanswered. For example, is evidence of disease in 
archeological bone tissue indicative of the fact that the indi- 
vidual had poor health during life? This question must be 
evaluated in comparison with an individual that has no skele- 
tal indicators of disease. Does dental hypoplasia reflect simi- 
lar disease conditions and processes as those that produce 
lesions in bone tissue? 

We also need a much stronger theoretical base on the evo- 
lution of disease and the dynamics of host/ vector interaction 
through time. BrothwelFs report on animal/human interac- 
tion in the transmission of disease in this volume offers in- 
sight and raises important questions on this issue. Clearly 
there is a dynamic relationship between the evolution of in- 
fectious agents and the immune response of individuals in the 
host population through time (e.g., Cockbum 1963; Fiennes 
1978). Infectious agents tend to become less virulent and the 
immune response of the host-population improves with se- 
lective evolutionary processes affecting both the agent and 
the host. However, what are the evolutionary mechanisms 
when the interaction between the infectious agent and the 
host is indirect. This appears to be the case in some of the 
erosive joint diseases where an infectious triggering agent 
initiates a genetically defective immune response that results 
in disease. 

Other theoretical issues include a careful understanding of 
what constitutes disease versus what constitutes a dysfunc- 
tional biomedical response. For example, we have known for 
some time that, in some environmental situations, disease 
may have a net benefit. Sicklemia in Africa and thalassemia 
in the Mediterranean region represent a biological adaptation 
to endemic malaria that has a net functional value despite the 
serious, generally fatal anemia that is associated with the 
homozygous expression of the disease. Stuart-Macadam 
suggests, in her report in this volume, that iron deficiency 
anemia may reflect a functional response to other infectious 
diseases. As we develop theory in paleopathology that inte- 
grates information from several disciplines, we need to in- 
sure that our terminology does not limit our interpretative 
options; that is, evidence of disease may, in fact, be indica- 
tive of adaptive biological responses to probleins. 

The role of population density in disease is another impor- 
tant theoretical question. We know very little about the rela- 
tionship of population density and disease in antiquity. For 
example, at what point in human history did viruses become 



a significant source of disease? Some viral infectious dis- 
eases require substantial population sizes and densities for 
maintenance (Fiennes 1978:20). McGrath's( 1 986) computer 
simulations suggest that some infectious diseases (e.g., hu- 
man tuberculosis) could not have been maintained in pre- 
historic Native American populations. This observation is in 
apparent opposition to paleopathological evidence that tuber- 
culosis was in fact present well before the 15th century. Are 
theoretical models ba.sed on modem medical experience ap- 
plicable to conditions extant in living archeological human 
populations? 

Related to this question is the important issue of whether or 
not paleoepidemiological research is possible with archeo- 
logical materials. Certainly one of the goals for paleopathol- 
ogy should be the establishment of epidemiological trends in 
antiquity. There clearly are theoretical and methodological 
limitations in doing this. We need to establish the potential as 
well as the limitations of paleoepidemiology. 

We know very little about the impact of culture change on 
human health. For example, what effect did rapid and trau- 
matic social change have on historic Native Americans? Is 
the apparent increase in infectious disease in these people due 
to exposure to new diseases for which they had minimal 
immunological experience and response or are social- 
psychological and other factors contributing as well? In try- 
ing to organize the topics and themes for the symposium, we 
have encouraged the authors of papers to review the status of 
research in their areas of special research interest. This re- 
view raises many questions about the nature and value of 
research conducted thus far. Asking good questions is the 
first step in getting good answers and making informed deci- 
sions about future research. Both reviewing the current status 
of research in paleopathology and exploring future options 
were objectives for the symposium and the published papers. 
A careful look at where we now are in paleopathology pro- 
vides the basis for a more informed process of choosing 
among the options for future research. We hope that we have 
been at least partially successful in achieving this objective. 



Literature cited 

Cockbum. A. 1963. The Evolution and Eradication of Infectious 
Diseases. Baltimore: Johns Hopkins University Press. 

Fiennes, R.N. 1978. Zoonoses and the Origins and Ecology of 
Human Disease. New York: Academic Press. 

Grmck, M.D. 1989. Diseases in the Ancient Greek World. Bal- 
timore: Johns Hopkins University Press. 

McGrath, J.W. 1986. A Computer .Simulation of the Spread of 
Tuberculosis in Prehistoric Populations of the Lower Illinois 
River Valley. Ph.D. dissertation. Northwestern University. Evan- 
ston. III. 

McNeill, W.H. 1976. Plagues and Peoples. Garden City. N.Y.: 
Anchor Press/Doubleday. 



Zagreb Paleopatttology Symp. 19HH 



Theory 



Theoretical and methodological issues 
in paleopathology 

Donald J. Ortner 



1 he progress of paleopathology, as a specific subject of 
research, parallels the development of many scientific and 
scholarly disciplines. This process includes an overlapping 
sequence of phases, each of which contributes to the objec- 
tive of improved understanding regarding the scientific sig- 
nificance of the discipline. Stages in development include: 
( 1 ) definition of a well-defined subject area of scientific inter- 
est and significance, (2) creation of a methodology for con- 
ducting research on the subject, (3) accumulation of a body 
of descriptive data related to the subject, (4) development of 
a classification system for what is observed, (5) generation of 
hypotheses regarding the scientific/scholarly significance of 
observed phenomena, and (6) relating data and hypotheses to 
similar research and theory in cognate fields. 

The progress made through each of these stages in pal- 
eopathology varies, but there is an emerging awareness of 
critical problems that need to be resolved before major fur- 
ther development can take place. The objectives of this paper 
are to explore the current status of research in paleopathol- 
ogy, highlight areas where problems and opportunities exist, 
and oft'er some suggestions on strategies for future research. I 
hope that most readers will understand that my emphasis on 
research in skeletal paleopathology reflects my own research 
bias and is not due to a failure to recognize the importance of 
other avenues of research. The principles expressed in this 
essay should, in fact, apply broadly to most research in pal- 
eopathology. 

Interest in pathological specimens from paleontological 
and archeological sites has existed for more than 150 years 
(Ortner and Putschar 1981:5). The establishment of pal- 
eopathology as a distinct focus of scientific research goes 
back at least to the early part of this century with the remark- 
able research and publications of RufTer, Elliot-Smith, 
Wood-Jones, Moodie, and others. This early research was 
largely descriptive and classificatory in nature, asking the 
question "what is it?" when confronted with a paleopatho- 
logical specimen. This emphasis on description continues to 
predominate in publications on paleopathology today. How- 
ever, another question, "what does it mean?" is being asked 
with increasing frequency and is forcing us to look more 

Zofinb Paleopathology Symp. J 988 



carefully at our descriptive methodology, classificatory sys- 
tem, and theoretical assumptions. This process reflects the 
recognition that paleopathology must, increasingly, address 
broader issues in the biomedical and anthropological sci- 
ences in addition to its well-established contributions to the 
history of human disease. 

Answers to the fundamental questions of "what is it?" and 
"what does it mean?" remain problematic in many ca.ses, 
although we are much further along with answers to the 
former question than the latter. Problems in responding to the 
question "what is it?" involve issues of description and clas- 
sification. The current reference point for such responses is 
in medicine and primarily with its subdisciplines of pathol- 
ogy and radiology. In this context, two issues are relevant to 
this essay. First, even in a modem clinical setting, it may be 
difl'icult or impossible to arrive at an accurate diagnosis (clas- 
sification) of a pathological condition affecting a living pa- 
tient. Second, even when diagnosis is possible in a modem 
medical patient, the necessary criteria may not apply or be 
available for classification of similar diseases in paleopatho- 
logical specimens. A response to the question "what does it 
mean?" requires an adequate base of data in which the ques- 
tion "what is it?" has been answered with reasonable scien- 
tific precision on a sufficient number of specimens. A re- 
sponse also requires a theoretical context in which issues of 
biological mechanisms, cultural influences, and strategies of 
human adaptation can be considered and evaluated. 

Significant progress in achieving creative responses to 
both these questions will depend on much greater attention to 
the methodological problems which now limit the utility of 
past and current research in paleopathology. For example, we 
need a method for describing pathological cases that provides 
information which can be evaluated independently by other 
observers. We also need to develop a classificatory system 
for paleopathology which will take into consideration the 
type and detail of infomiation that is available and can be 
evaluated in a paleopathological specimen. This will almost 
certainly mean that we will be including some features that 
arc not presently part of the classificatory system associated 
with orthopedic radiology and pathology. This cannot, of 

5 



6 • Donald J. Ortner 




Figure 1 . Destructive lesions of anterior, lum- 
bar vertebral bodies and sacrum. (Child about 1 2 
years from medieval cemetery associated with 
hospital of St. James and St. Mary Magdalene, 
Chichester, England.) 



course, be done in isolation from modem medicine, but will 
stimulate questions for medical colleagues which address 
classificatory problems of paleopathology in terms of the 
data and observations unique to that discipline. 

We also need to achieve an improved understanding of the 
theoretical implications of our findings in paleopathology. 
Does, for example, an increased prevalence of skeletal infec- 
tious disease in a skeletal sample mean that the living group 
of people represented by this sample was less healthy than a 
skeletal sample which has fewer cases of infectious disease? 
There are complex immunological, pathological, and demo- 
graphic issues in such a situation that must be understood 
before reasonable conclusions can be reached. Angel's (e.g., 
1966) studies of skeletal changes in thalassemia and the sig- 
nificance of evidence for this disease in archeological skele- 
tal samples from the Eastern Mediterranean provide a semi- 
nal example of this kind of research. 

Methodological issues in paleopathology 

One of the problems in paleopathology may be an over- 
reliance on clinical diagnostic criteria. Paleopathologists try 
to fit their observations into a descriptive and classificatory 
system that has been developed for different objectives, 
namely the treatment of living patients. There are many fea- 
tures apparent in a paleopathological skeleton that have no 
direct correlate in clinical medicine. For example, the obser- 
vation in the medical literature that spinal tuberculosis usu- 
ally predelicts the vertebral bodies (e.g., Schinzet al. 1951- 
1952:571; Resnick and Niwayama 1981:217; Ortner and 
Putschar 1981:145) may mean only that radiological evi- 
dence for involvement of the posterior elements is rarely 
observed. 



A case of spinal lesions in the skeleton of a 12-year-old 
child (Burial no. S-21 1) from the cemetery site associated 
with the medieval hospital of St. James and St. Mary Mag- 
dalene in Chichester, England, illustrates the problem. De- 
structive lesions are apparent on the anterior surface of the 
vertebral bodies in the lower spine and sacrum (Figure 1). 
Periosteal reactive bone is seen on some of the vertebral 
arches (Figure 2). Other bones in the skeleton are not af- 
fected. 




Figure 2. Proliferative, reactive bone on lumbar vertebral 
arches. (Child about 12 years from medieval cemetery asso- 
ciated with hospital of St. James and St. Mary Magdalene, 
Chichester, England.) 



Zitfirvh Pateopalhology Symp. 1988 



Theoretical and methodological issues in paleopathology • 7 



Both bacterial (e.g. . Mycobacterium iitherculosis and Sio- 
phylococciis aureus) and mycotic (lungai) infection should 
be considered in differential diagnosis. Almost certainly the 
proliferative lesions apparent on the vertebral arches would 
not be seen in an x-ray film of a living patient. They thus 
might not be part of the clinical understanding of skeletal 
involvement in any of the diseases that could have produced 
the lesions seen in this case. In view of this possibility one 
needs to exercise caution in rejecting tuberculosis as a diag- 
nostic option simply because of atypical, reactive bone for- 
mation on some of the arches. This is particularly true in view 
of diagnostic probabilities suggested by the high prevalence 
of tuberculosis in England from the latter part of the medieval 
period until the dramatic decline in this century. 

It is possible, of course, that the lesions were caused by 
another bacterium such as Staphylococcus or by fungi, al- 
though the latter disease is rare in recent medical history. The 
crucial point is that the skeletal paleopathologist often sees 
details of bone involvement in paleopathological cases that 
include features not normally associated with modem clini- 
cal cases. The existence of such lesions requires careful 
thought and evaluation with the limitations of clinical experi- 
ence being given appropriate consideration. 

The high prevalence of periosteal lesions on the tibia is 
another example of a common observation in North Ameri- 
can archeological skeletons that is rarely seen or noted in a 
clinical context. Paleopathologists have difficulty in inter- 
preting the significance of this condition, particularly in 
cases where there are no additional lesions in other parts of 
the skeleton. Trauma and infection are likely to be the most 
common causes of such lesions. We are, however, unlikely to 
differentiate a specific cause for many, if not most, cases of 
this condition without further anatomical/histological stud- 
ies in modem clinical cases. 

Close cooperation between paleopathology and clinical 
medicine is an obvious and critical need in paleopathological 
research. Research in skeletal paleopathology is now explor- 
ing the diagnostic boundaries of clinical orthopedic disease. 
We are starting to ask questions for which there is no obvious 
clinical knowledge. Many of these questions are significant 
for both research in paleopathology and an improved under- 
standing of orthopedic pathology. Collaboration between the 
paleopathologist and various medical specialists is likely to 
provide a more complete picture of skeletal responses to 
disease. 

Dr. Bruce Ragsdale, a pathologist with a specialty in 
orthopedic diseases, and I are collaborating in studies of joint 
disease, in an attempt to answer some of the questions raised 
in paleopathological research (Figure 3). One important 
question is, what are the soft tissues associated with some of 
the lesions seen in joint diseases? Such research can be con- 
ducted in some situations once the problem is defined, but 
may be very difficult to do in conditions that rarely, if ever, 
are brought to the attention of the clinician. 




Figure 3. Macerated proximal tibia from a modem case of 
joint disease with a section through a lesion of the joint 
surface removed before maceration. Clinical history, ante- 
mortem and specimen x-ray films, and histological prepara- 
tions of the section are being studied. 



Another illustration of the potentially productive relation- 
ship that can exist between paleopathology and clinical medi- 
cine is seen in the skeletal changes associated with the vari- 
ous syndromes of inflammatory erosive joint disease. Ortner 
and Utermohle (1981) published a case of polyarticular ero- 
sive joint disease in a pre-Columbian female skeleton from 
Kodiak Island, Alaska. The authors suggested that the most 
likely syndrome for this case was rheumatoid arthritis. The 
pattems of most lesions, as well as the distribution of os- 
teoporosis, were major features supporting this opinion. The 
problem with this diagnostic option is the extensive and se- 
vere involvement of sacroiliac and spinal joints in the disease 
process. 

Clinically, spinal and sacroiliac joint destmction is thought 
to be rare in rheumatoid arthritis. The questions posed by this 
case include: ( t ) how often is the spine and sacroiliac joint 
involved in clinical cases of rheumatoid arthritis and (2) to 
what extent is the failure to observe spinal and sacroiliac joint 
involvement in rheumatoid arthritis an artifact of the limita- 
tions of radiology? The answer to both of these questions is 
important to both clinical medicine and paleopathology. 
Since raising these questions, colleagues in rheumatology 
have showed me two cases of rheumatoid arthritis that have 
clear evidence of erosive changes in the sacroiliac joint. I 
suspect that other parts of the spine are involved as well, but 
such changes are not well known clinically because of the 
limitations of radiological imaging. The significance is that a 
paleopathological case raised diagnostic questions which re- 
quired a second and more careful look at clinical cases. This 
process has been a valuable experience for both the pal- 
eopathologist and the clinician. 



Zagreb Paleopathology Symp. l9fiH 



8 • Donald J. Ortner 



Clinical diagnosis of orthopedic diseases relies heavily on 
observations derived from radiology. Several conditions lim- 
it the value of this perspective for research in skeletal pal- 
eopathology. First, radiologists rarely take an x-ray film un- 
less a patient has a complaint of some type. Clinical 
orthopedic radiology is thus based on a human sample that 
has a medical problem to begin with. In addition, the radiolo- 
gist takes only the x-ray films needed to evaluate the com- 
plaint of the patient. The implication of this is that the total 
pattern of skeletal involvement in orthopedic diseases may 
not be well known. 

Furthermore, most radiologists concede that a change in 
bone density on the order of magnitude of forty percent is 
necessary before a pathological change can be seen on a 
clinical x-ray film. This means that many of the more subtle 
changes apparent on a dry-bone specimen will not be part of 
the experience of the radiologist and will thus not be part of 
the radiological descriptive and classificatory system. The 
overall pattern of various types of lesions in a skeleton is an 
observation that is accessible to the paleopathologist (when 
skeletal preservation is good) and is certainly of critical im- 
portance in evaluating paleopathological specimens. To uti- 
lize fully this type of observation will require thoughtful 
feedback from clinical experience and additional research on 
total patterns of skeletal disease in known cases. 

Another major problem in paleopathology is the lack of 
comparability between reports on abnormal specimens, 
which precludes meaningful comparison of data. There are 
two major reasons for this: ( 1 ) the knowledge about skeletal 
disease varies greatly between observers, and (2) there is no 
consistent protocol for the types of data included in various 
reports, so that different scholars observe different condi- 
tions. If paleopathology is to address important questions 
regarding, for example, the evolutionary significance of dis- 
ease, we must improve the comparability for both content 
and quality of our observations. 

Recently I was coauthor of an invited manuscript on hu- 
man health and disease in the Mesolithic and Neolithic ages 
(Ortner and Theobald 1987). The research for this manu- 
script included a survey of published observations and data 
on disease in archeological skeletons from sites dated to the 
Mesolithic and Neolithic ages in the Near East, Eastern Med- 
iterranean, Europe, and the USSR. In these geographical 
areas, over 1 200 human skeletons dated to the Mesolithic and 
more than 12,000 skeletons dated to the Neolithic Age have 
been reported in the literature. 

One of the major problems in these published sources is 
that most authors offer an opinion on diagnosis of pal- 
eopathological specimens without carefully describing the 
type and location of lesions. This effectively prohibits an 
independent evaluation of these cases. This limits any state- 
ments regarding variation in disease prevalence in antiquity 
to highly speculative observations. The obvious strategy is to 
develop and apply a descriptive methodology to the analysis 



and publication of pathological specimens that does not nec- 
essarily preclude classification or diagnosis but, at the very 
least, permits the reader to reach his or her own conclusion 
regarding the nature of the pathology, without having to ac- 
cept the diagnostic opinion of the author. 

To achieve this objective, a much greater emphasis is 
needed in paleopathology on describing the abnormal condi- 
tions seen in archeological human remains. There are two 
dimensions of such a descriptive methodology. First, we 
need a widely accepted method to describe the types of ab- 
normal conditions that exist, using criteria that reflect the 
underlying pathological processes. Second, we need to 
show, in detail , the location of all abnormal conditions within 
a paleopathological case. Application of a good descriptive 
methodology, including the type and location of lesions, to 
the analysis of archeological skeletal samples would be a 
major step in providing descriptive data that would allow 
independent evaluation of pathological conditions. 

Description of the type of lesion should be based on the 
activity of the cells that produce the lesion. Three basic con- 
ditions exist: (1) formation of abnormal mineralized tissue 
(osteoblasts), (2) destruction of existing mineralized tissue 
(osteoclasts), and (3) a combination of both processes either 
in different parts of a lesion or different areas of the skeleton. 
Any descriptive system should include, at least, this informa- 
tion about skeletal lesions. There is, in addition, consider- 
able variation in the amount and shape of the abnormal 
mineralized tissue that is formed, which adds to our under- 
standing of the pathological process. The rapidity of bone 
loss in destructive lesions is indicated by the morphology of 
lesion margins. This is a diagnostic feature that is apparent in 
paleopathological specimens and can be linked with radi- 
ological diagnostic criteria. There are also abnormalities in 
the size and shape of bones as seen, for example, in the 
dysplasias and rickets. 

Describing the type and location of abnormal conditions is 
a far less complex problem than arriving at an accurate diag- 
nosis. Furthermore, it is the type of data that can be trans- 
ferred across disciplinary lines with relative ease, and pro- 
vides an important basic step in the diagnostic process. It also 
pennits reevaluation by other scholars who can arrive at a 
different opinion on the diagnosis if their evaluation of the 
data so warrants. 

Computer-aided design (CAD) software can be helpful in 
such research. In my laboratory we have been exploring the 
application of AutoCAD, a CAD software package devel- 
oped by Autodesk, Inc., U.S.A., to research in skeletal pal- 
eopathology (Figure 4). This software has many powerful 
features. One is the ability to enlarge or reduce images. 
Another feature is the potential of putting different types of 
lesions on different layers of the CAD record for a pal- 
eopathological specimen. One or more of these layers can be 
turned on or off to clarify patterns and relationships between 
different kinds of lesions. 



Zagreb Paleopathology Symp 1 9118 



Theoretical and methodological issues in paleopathology * 9 




NMNH 385788 



■^ 

■^ 




C^^ 



CBlastic 



CLytic 



CMixed 



Figure 4. Computer-aided design drawing of the pattern of various types of lesions in a probable case of 
treponematosis from a pre-Columbian archeological site in Virginia, U.S.A. Note the pattern of proliferative 
bone lesions (Elastic) versus those that are largely destructive (Lytic) in nature. (Drawing based on an adult 
male skeleton from the Fisher Site, Virginia. U.S. National Museum of Natural History Catalog No. 385788.) 



At the moment, however, the process of generating a 
graphic image showing the distribution of lesion types in a 
skeletal specimen is tedious and time consuming. In cases 
where there are several different types of lesions and a com- 
plex distribution pattern, CAD may offer important insight 
regarding the pathological process and is well worth the time 
investment. Eventually, when the system is developed fur- 
ther, it will be much easier to use. We also anticipate develop- 
ing a data base management system to store the data which 
will allow statistical analysis of types of lesions. 

Theoretical issues in paleopathology 

Theory in paleopathology is poorly developed at present. 
This, in part, reflects the problems in the data base discussed 
above. There are, however, some tentative scholarly probes 
in paleopathological research that are starting to raise impor- 
tant theoretical issues. Research on skeletal disease in hunter- 
gatherer, as compared with agricultural skeletal populations, 
is one example (Cohen and Armclagos 1984). Clearly an 
improved theoretical context will become increasingly im- 
portant as we continue to ask questions about the broader 
meaning of our data and observations. 



One of the fundamental questions within the context of 
paleopathological evidence of infectious diseases now being 
asked is "what does the presence of infectious lesions of the 
skeleton mean, for both the health of the individual and the 
population from which such an individual comes?" There is, 
of course, a fundamental question about accuracy in diag- 
nosis of infectious lesions. Assuming, for the moment, that 
such a diagnosis is possible and is accurate, we can begin to 
interpret the significance of such findings. Is. for example, 
an increased prevalence of skeletons with infectious lesions 
in a population an indicator of poor health for that popula- 
tion'.' 

The easy assumption is that a relatively high prevalence of 
cases of infectious skeletal disease in a skeletal sample is, 
indeed, indicative of decreased population health. This may, 
in fact, be true, but additional evidence is likely to be needed 
to support this conclusion. The reason this assumption might 
not be true lies in the nature of the bone tissue response to 
infectious disease. In some cases of skeletal infection, the 
primary site is bone (e.g., septic arthritis). More commonly, 
however, involvement of the skeleton in infectious disease 
occurs late in the disease process (e.g. , treponematosis). This 
means that the individual with the disease must survive the 



Zagreb Paleopathology Symp. 1988 



10 • Donald J. Ortner 



initial, often acute, phase of infection before the skeletal 
manifestations occur (Ortner and Hunter 1981). This implies 
a good immune response and a relatively healthy individual, 
in contrast with a person having the same disease who dies 
before the bone tissue is affected by the disease process. 

It is at least theoretically possible that evidence of skeletal 
infectious disease may really be evidence of a good immune 
response to disease, and thus evidence of relatively good 
health. Certainly such an immune response is not as effective 
as one that successfully rids the body of the infectious organ- 
isms during the early stages of the disease. Nevertheless, it is 
clear that many of the infectious conditions encountered in 
archeological skeletons represent a long-temi chronic re- 
sponse to the infectious agent. Resolution of the implications 
of this observation requires careful attention to demographic 
data, among other things, for the skeletal sample in question. 
1 would want to know, for example, that individuals with 
evidence of skeletal disease were dying at a younger average 
age than individuals without such evidence. It also requires 
an understanding of the immunological responses to disease 
and their relationship to skeletal involvement. The point to be 
made is that, as paleopathoiogists begin to ask questions 
concerning the meaning of our observations, we must be very 
careful that our assumptions take into consideration all of the 
possible skeletal responses to disease. 

Resolution of many of these questions regarding the mean- 
ing of our data and observations involves complex issues and 
knowledge inherent in several disciplines. Nevertheless, it is 
essential that paleopathology make a significant effort to 
move beyond the diagnostic phase of research , and ask ques- 
tions about the biological and evolutionary significance of 
our findings. At the very least, we need to clarify the role 
disease has played in the complex process of adaptation be- 
tween human groups and their environment. 

in the last ten thousand years there have been major 
changes in mankind's relationship with the environment. The 
predominant economic subsistence pattern has shifted from 
hunting-gathering to agriculture. There have been major 
changes in settlement patterns with relatively dispersed, 
mobile human groups giving way to sedentary, major con- 
centrations in small geographical areas as in the cities of 
today. Both of these epochal changes must have had a major 
impact on the prevalence of many diseases, but particularly 
on infectious conditions, thus representing a major challenge 
for research in paleopathology. 

Conclusions 

The flood of books and papers on paleopathology in the past 
twenty years is beginning to reveal some interesting scien- 
tific opportunities as well as some fundamental theoretical 
and methodological problems. These must be addressed if 
paleopathology is to make further significant contributions to 
both anthropological and medical theory and knowledge. 



Perhaps the most serious problem is the current inability to 
use most of the data on paleopathology found in published 
sources for comparative research. There is considerable vari- 
ability, both in the quality of paleopathological observations 
and in the types of disease conditions included in the data 
protocols of the source materials. A partial solution to this 
problem would be to develop and dis.seminate descriptive 
terminology and methodology that are less dependent on a 
sophisticated knowledge of pathology and radiology. The 
emphasis would be on careful description of abnormal condi- 
tions rather than reaching a diagnostic conclusion. Such a 
procedure will permit independent review of differential di- 
agnosis in publications on paleopathology. We also need to 
reach a consensus on the minimal types of diseases that 
should be included in all paleopathological studies. 

Such descriptive methodology would permit a more mean- 
ingful way of integrating data and observations from multiple 
research sources. It is now very difficult for one person to 
collect all the data needed for a regional study of paleopathol- 
ogy. The relatively few cases (ca. fifteen percent) affected by 
disease in a skeletal sample requires screening large numbers 
of skeletons in order to obtain meaningful data. Problems in 
funding, access, travel, and the sheer amount of material 
available for study mean that we must develop a methodol- 
ogy that will permit independent analysis by scholars who 
may not be able to study the original specimens. It is likely 
that there will always be problems in doing this, but the 
development and widespread use of a rigorous descriptive 
methodology with a precise terminology for skeletal lesions 
and their location in the skeleton would bring this goal much 
closer to reality. If carefully done, such data can be rein- 
terpreted by other observers and integrated with data from 
other similar studies. Computer-aided design software offers 
an important potential research tool in recording distribution 
patterns of skeletal disease. 

Emerging technology, particularly in the areas of chemis- 
try and microscopy (both light and scanning electron micro- 
scopes), may offer important insight for paleopathological 
research. Bone is a tissue, as well as an organ, and responds 
to a variety of systemic conditions at the molecular, micro- 
scopic as well as at the gross level of biological organization. 
Immunoproteins can now be detected at the parts per billion 
level. If antibodies, or other proteins linked to the disease 
response in the body, survive in archeological skeletal tissue 
they can now almost certainly be detected and analyzed. 
Currently, 1 am collaborating in preliminary research on im- 
munoproteins in archeological bone tissue that is promising. 
Other chemical studies of abnormal bone tissue can also 
assist in understanding the pathological process involved 
(Von Endt and Ortner 1982). Such research may open up new 
and important sources of data in paleopathology. 

Paleopathology has made minimal effort to use micro- 
scopic data in archeological specimens, because the biolog- 
ical significance of many microscopic features apparent in 



Zagreb Paleopathology Symp 1988 



Theoretical and methodological issues in paleopathology • 1 1 



bone is poorly understood (Richman, Ortncr. and Schulter- 
Ellis 1979). Use of this potential source ot data will require 
basic research on the biological significance of these features 
and on standards for distinguishing normal histological pat- 
terns from abnormal. 

There are, of course, practical limits on what we can say 
about major processes, including diseases that affect human 
populations. Almost certainly there are new diseases today 
that were not present in antiquity and vice versa. It is also 
likely that the skeletal response in some disease processes has 
changed. The evolutionary tendency for infectious agents to 
become less virulent with time (Cockbum 1963) will in- 
crease the probability that older diseases will be more chronic 
in their relationship to the host. Infectious diseases that prog- 
ress to a chronic phase are more likely to affect the skeleton. 
This means that some skeletal disease processes apparent in 
archeological specimens will have minimal impact on overall 
biological function or longevity, and may not be the primary 
cause of death. A response to the question regarding the 
broad meaning of our descriptive data will require careful 
thought about the implications of this and other similar facts. 

Paleopathology has at least the potential to contribute to 
our understanding of several important processes including: 
{ 1 ) the biological and evolutionary role of disease in human 
societies, particularly as reliable data on disease prevalence 
accumulates. (2) the complex relationships between disease 
and the epochal social changes that took place in human 
history, such as sedentism and urbanism. and (3) the bio- 
medical response of the skeleton to disease. 

To achieve this added insight, however, we must get our 
methodological and theoretical house in order. We will need 
to avoid easy assumptions based on inadequate knowledge of 
pathological processes in bone tissue. As we develop a great- 
er research emphasis on hypothesis testing and theory devel- 
opment in paleopathology, we must deal more effectively 
with the broad theoretical implications of our research. We 
must give more careful thought to the biological significance 
of evidence for infectious and other diseases in the skeleton 
and their significance for population morbidity. While en- 
lightened speculation may be helpful . it is very easy to careen 
down scientifically blind alleys because of ignorance or be- 
cause we have overextended our data. If we hope to achieve 
the full potential of research in paleopathology we must avoid 
doing this. 

Literature cited 

Angel. J.L. 1966. Porotic Hyperostosis. Anemias, Malarias and 
Marshes in the Prehistoric Eastern Mediterranean. Scieme. 
153:760-763. 

Cockbum. A. 1963. The Evolution and Eradictilion oj Infectious 
Diseases. Baltimore: Johns Hopkins University Press. 



Cohen, M.N.. and G.J. Armclagos. eds. 1984. Paleopathology at 
the Orifiins of A^riiuliurc . New York; Academic Press. 

Ortncr. D.J.. and.S. Hunter. 1981. Hematogenous Osteomyelitis in 
a Pre-Columbian Child's Skeleton Irom Maryland. MASCA Jour- 
nal. 1:236-238. 

Ortncr, D.J.. and W.G.J. Pulschar. 1981. Identification of Patho- 
logical Conditions in Human Skeletal Remains. Smithsonian 
Contributions to Anthropology, 28. Washington. D.C.: Smithso- 
nian Institution Press. 

Ortncr. D. J. . and G . Theobald. 1 987 . Human Health and Disease in 
the Mesolithic and Neolithic Ages. Manuscript. 

Ortncr. D.J.. and C.J. Utermohlc. 1981. Polyarticular Inflamma- 
tory Arthritis in a Pre-Columbian Skeleton from Kodiak Island. 
Alaska. American Journal of Physical Anthropology. 56:23-3 1 . 

Rcsnick. D. . and G. Niwayama. 198 1 . Diagnosis of Bone and Joint 
Di.sordcrs. Philadelphia: W. B. Saunders. 

Richman. K.A., D.J. Ortner, and F.P. Schuller-Ellis. 1979. Differ- 
ences in Intracortical Bone Remodeling in Three Aboriginal 
American Populations: Possible Dietary Factors. Calcified 
Tissue International. 28:209-214. 

Schinz, H.R., W.E. Baensch, E. Friedl, and E. Uehlinger. 1951- 
1952. Roentgen Diagnostics: Skeleton. 2 volumes. English trans- 
lation by J.T. Case. New York: Gmne and Stratton. 

Von Endt, D.W., and D.J. Ortner. 1982. Amino Acid Analysis of 
Bone from a Possible Case of Prehistoric Iron Deficiency Ane- 
mia. American Jounuil of Physical Anthropology, 59:377-385. 



Summary of audience discussion: Granted the need for a funda- 
mental change in both the content and methods of palcopathological 
research, stimulating the necessary changes is a challenging task. 
Part of the problem is that paleopathologists include anthropologi- 
cally and medically trained specialists and each type brings a differ- 
ent knowledge, experience, training, jargon, and methodology to 
the subject. Both the anthropological and medical disciplines are 
necessary for palcopathological research, and a good palcopatholo- 
gist must become as knowledgable as possible about both disci- 
plines. Equally important is that each type of specialist should 
cultivate collaborative relationships with specialists in the other 
discipline. 

Basic to both, however, is a methodology that places a strong 
emphasis on careful description of the abnormal conditions we see. 
There will be problems in language but these will be minor if the 
basic description is done carefully. The paleopathologisi also needs 
to develop a elassificatory system that lakes lull advantage of the 
data available in the material being studied. We need ongoing dia- 
logue between the paleopathologists and medical colleagues to in- 
sure as much overlap as possible with extant medical lemiinology 
and elassificatory (diagnostic) categories. 

If significant progress is to be made in paleoepidemiological 
research much more comprehensive skeletal samples will be needed 
to provide the data for both synchronic and diachronic research. 
One person is unlikely to be able to study all the necessary speci- 
mens, so a carefully considered and generally accepted descriptive 
and elassificatory methodology is a critical need. 



Zagrtb Paleopathology Symp. 1988 



Is paleopathology a relevant predictor 
of contemporary health patterns? 

Susan Pfeiffer 



(current actions in many parts of the world toward deacces- 
sion or reburial of skeletal material have stimulated more 
public discussion of paleopathoiogists' goals and achieve- 
ments. The motto of the Paleopathology Association, Morliii 
viventes docent (the dead are our teachers), suggests that we 
are learning things that are relevant to our contemporary 
context. As Kerley and Bass noted in 1967, "having some 
knowledge of past history, one is better able to predict the 
course of future events." But how specific can these predic- 
tions be? Our past research has often demonstrated the effects 
of ecological change on morbidity profiles (cf. Saul 1972). 
Our lobbying material contains references to the potential for 
insights into disease processes and analogies between past 
and current ailments (cf. Neiburger 1987; Pfeiffer 1980). 
However, information about past populations' mortality and 
morbidity is only scientifically useful if it is somehow predic- 
tive: if it can help us predict for a specific population their 
susceptibility to a pathogen, or the incidence of a congenital 
anomaly, or the effect of an environmental stressor on their 
growth/aging. Hence, while accepting as given the very val- 
uable historical function performed by paleopathology, I 
wish to explore its ability to help us anticipate and solve 
contemporary health problems. I will argue that methodolog- 
ical limitations constrain the role that paleopathology can 
play. Nevertheless, it can help us predict modem disease 
susceptibility. Its value may sometimes lie in simple con- 
tinuities or analogies. In other instances it may help us under- 
stand the commonalty of biological response which in an- 
cient times led to one outcome, but in modern times may lead 
to quite another. 1 intend to search for such links in popula- 
tions where palcopathological study has been relatively in- 
tensive, and with which I am familiar, namely the Indian and 
Inuit populations of Canada. 

What makes the past relevant? 

The dead can teach us about the living only if there is com- 
monalty between the two. This commonalty may be genetic, 
behavioral, and/or environmental. Genetic continuity from 
past to contemporary populations is never complete, and 



quantitative estimates of genetic heritage are rarely available. 
Perhaps wisely, literature on population differences in disease 
pattern usually refers to "ethnicity" (a sociological term) 
rather than "race" (a biological term ) (Cooper 1 986). Associa- 
tion with an ethnic group may indicate only a general hint 
about biological heritage. For example, through Canada's 
Indian Act of 1 876 one was defined as a status Indian only if 
one's male line was Indian in 1874. If an Indian woman 
married a non-Indian, all subsequent progeny were disen- 
franchised, while the progeny of an Indian man and a non- 
Indian were all status Indians (Price 1979). Federal legislation 
changed this operational definition in 1987. Such arrange- 
ments illustrate how tentative the genetic links between past 
racial groups and current ethnic groups may be. 

Partial behavioral continuity may occasionally occur be- 
tween past and present populations, in that contemporary 
populations may eat the same diet, build the same dwellings, 
or perform the same subsistence activities as their pre- 
decessors. However, such situations will be rare, such as 
purposeful attempts by northern Canadian natives to "go 
back to their roots" or "live off the land." Ostensibly, pal- 
copathological evidence could tell such groups what health 
risks they might face. In practice, however, no large groups 
have fully adopted prehistoric native technology and di- 
vorced themselves from outside institutional support (Tung- 
avik Federation of Nunavut 1987). 

Environmental continuity of past and present populations 
is certainly possible. Although the mix of large plants and 
animals may change, as well as the intluences of human 
population density, there may also be continuity in some of 
the pathogens endemic to a region. And, obviously, the arctic 
stays cold, the tropics stay hot. Paleopathology could in 
some special cases offer information about the climatic or 
pathogenic hazards of an environment. However, such infor- 
mation is likely to supplement other sources, and is very 
unlikely to be superior to those other sources. 

Hence, there appears to be genetic/behavioral/cnviron- 
mental continuity between past and present populations only 
if these categories are sketched very broadly. In certain cases, 
any of these three overlapping categories may offer a strong 



12 



Zagreb Paieopalhology Symp. 1 988 



Is paleopathology a relevant predictor of contemporary health patterns? • 13 



case for prediction through homology, hut a more general 
analogous argument will more likely be appropriate in most 
cases. 

Nature of paleopathological evidence 

The physical remains that form the basis for most pal- 
eopathological study have both attractive and unattractive 
features. Their attractive characteristics include their poten- 
tial time depth. It is possible to examine the physical remains 
of a cultural lineage ranging over thousands of years, and 
hence ascertain the antiquity of certain maladies, as well as 
how they vary with behavioral or environmental shifts. Sim- 
ilarly, paleopathological evidence often allows observations 
of great geographic breadth. A particular condition can be 
traced throughout an environmental zone, or between one 
cultural lineage and its neighbors. Nonmummified remains 
offer a view of skeletal and dental changes that is unobscured 
by overlying soft tissue: there is no need to find noninvasive 
modes of investigation or to weigh the value of information 
gathered against the danger of radiating the patient. In most 
dry and mummified remains, evidence is of unmodified, 
untreated disease processes. Hence, there is no need to factor 
out iatrogenic effects. 

On the other hand, paleopathological evidence is seriously 
limited. When we approach the remains clinically, the ab- 
sence of .soft tissue severely limits the accuracy of a dilTcr- 
ential diagnosis. There is no opportunity to establish symp- 
tomatology, no disease progress to follow. Hence our 
confidence in our diagnosis is often limited. Further limita- 
tions on diagnosis are imposed by the relatively nonspecific 
reactions of bone tissue to extrinsic stressors. Paleopatholo- 
gists must be particularly cautious diagnosticians. 

Perhaps the remains' most serious fault for purposes of 
health status prediction is their serendipitous nature. Patterns 
of human burial and mummification are very diverse, and 
retrieval of remains is relatively rare. Phillip Tobias noted in 
1982 that South African hominids were represented by 51 1 
individuals spanning over 3 million years; that is, one indi- 
vidual for every 5871 years {Tobias 1983). So too. the evi- 
dence of more recent human populations is sporadically dis- 
tributed and not much more complete. Because of this lack of 
control over sampling, paleopathological evidence tells of a 
disease's existence but not of its prevalence nor its incidence 
(Moore et al. 1980). This seriously limits our ability to pre- 
dict the probability of a condition's modern occurrence. 

Nevertheless, progress has been made in establishing an 
epidemiological approach to paleopathology, in which fea- 
tures due to abnormal bone remodeling dynamics (or enamel 
formation) are observed in all elements from all skeletons of 
an archeological skeletal scries, and patterns of incidence are 
tested against specific models (Buikstra and Cook 1980). 
Further, there are certain special ethnographic settings in 
which the skeletal remains recovered may approximate an 



unbiased sample of a Mendelian population. The practice of 
ossuary burial among Iroquoian people of southern Ontario is 
one example of such a setting (Trigger 1969,1976). 

Given this list of .strengths and weaknesses, I will identify 
a number of conditions which particularly jeopardize north- 
em Indian and Inuit health, and attempt to see what insights 
or predictions the paleopathology of these groups may offer. 
The discussion of current native health problems is not com- 
plete, but rather emphasizes skeletal traits, or conditions 
which may be linked in some way to skeletal metabolism. 

Health problems of Native Americans 

The conditions of greatest public health interest among Na- 
tive Americans are those of the so-called "New World Syn- 
drome": obesity, adult-onset diabetes mellitus, gallstones, 
and gallbladder cancer (Weiss et al. 1984). Other conditions 
to which Native Americans appear particularly susceptible 
include the infectious diseases tuberculosis and otitis media, 
plus a number of hereditary or partially hereditary condi- 
tions: hereditary polymorphic light eruption, rheumatoid ar- 
thritis, oral clefts, hyperbilirubinemia, Polydactyly, and con- 
genital dislocation of the hip(Sieversand Fisher l98l;Criss 
1 985). Not all these conditions show a high relative incidence 
in all native groups. Furthermore, other conditions not listed 
here may constitute major health problems for some Native 
American groups. Among many groups, alcoholism and cir- 
rhosis are common causes of morbidity and mortality. Acci- 
dents account for more fatalities among natives than among 
non-natives for a variety of reasons. 

Note that neoplasms and coronary heart disease, which are 
the most common causes of mortality among middle class 
North Americans, are not major cau.ses of mortality among 
Native Americans. This is at least partially explained by the 
relative youth of the native population. In Canada, only 3% 
of the native population is over age 65 years compared to 9% 
over age 65 among non-native Canadians (Statistics Canada 
1984). In 1981 , Indian males could expect to live an average 
of 9.5 years fewer than the Canadian national male popula- 
tion, while Indian women could expect to live an average of 
lO.Oyears fewer than the national female population (Maoet 
al. 1986). In the United States, too. the median age of natives 
is low: 20.5 years, as compared to 28.9 years for White 
Americans (Criss 1985). 

Relevance of paleopathology 
to congenital conditions 

Several of the hereditary conditions listed above are manifest 
in the skeleton, and could be traced through paleopathologi- 
cal cases. Polydactyly is the most prevalent major birth de- 
fect in natives at 2.4 per KKM) live births (Niswandcr el al. 
1975). Its antiquity has been argued from prehistoric rock art 
depictions (Wcllmann 1972). However we cannot ascertain 



Zagreb Paleopathology Symp. 1988 



14 • Susan Pfeiffer 



the incidence of the trait from such evidence. Hence, pal- 
eopathology can show us that this trait, which is a common 
developmental anomaly in many species, is ancient in hu- 
mans; it can even suggest that ancient humans thought it 
noteworthy. It is unlikely to tell us anything new about Poly- 
dactyly. 

Congenital dislocation of the hip, which is especially com- 
mon among certain Canadian native groups (6% among 
Cree-Ojibway; Corrigan and Segal 1950; Walker 1975), has 
also been documented in prehistoric remains (Clabeaux 
1977). Several authors have postulated that hip dislocations, 
sometimes incorrectly considered a correlate of generalized 
joint laxity {Walker 1975), represent a genetic tendency exac- 
erbated by cradle-boarding. Contemporary cross-cultural 
studies have been inconclusive (see Sievers and Fisher 1981 
for discussion). A comparison of incidence between pre- 
historic Cree-Ojibway remains and contemporary popula- 
tions would offer valuable evidence regarding the effect of 
cradle-board binding on hip development. However, no sub- 
stantial Cree-Ojibway samples have been excavated to date. 
A number of small samples would need to be combined and 
compared carefully to gather accurate incidence data. 

Rheumatoid arthritis is another example of a congenital 
tendency which may be exacerbated by environmental condi- 
tions. Its contemporary incidence is particularly high among 
Haida Indians of the Northwest Coast (Gofton et al. 1964; 
Lawrence et al. 1966). The absence of reported prehistoric 
cases has led some authors to suggest a recent origin for the 
condition, perhaps triggered by some environmental change 
(Short 1974). However, it is more likely that the absence of 
paleopathological cases is due to uncertainty of the diagnosis 
of rheumatoid versus traumatic arthritis or degenerative joint 
disease (DJD). Progress is now being made in differentiating 
the two (cf. Leisen 1986). Since relatively large isolated 
prehistoric skeletal samples are accessible from the geograph- 
ic areas in question, it may now be possible to use paleopatho- 
logical evidence (or lack of evidence) to elucidate which 
environmental factors are relevant to the development of 
rheumatoid arthritis in these native groups (cf. Cybulski 1978). 



groups are especially susceptible to the condition when 
bottle-feeding is practiced. The potential relevance of pal- 
eopathology to the problem of otitis media has recently been 
argued by Daniel et al. ( 1988). 

Tuberculosis has been a great source of native mortality in 
historic times, and it continues to be found more commonly 
among natives than among non-natives (Enarson and 
Grzybowski 1986). In 1975, native deaths from tuberculosis 
were8.3 times higher than the U.S. national average (Sievers 
and Fisher 1981). This increased susceptibility was first 
thought to reflect the natives' virgin immunological status 
upon European contact (cf. Dubos 1965). However, the dis- 
covery of acid-fast bacilli in indisputably pre-Columbian 
mummified tissue (Allison et al. 1973) disproved this idea. 
Evidence of tuberculous-type lesions in various pre- and pro- 
tohistoric native samples is accumulating (cf. Pfeiffer 1984; 
Hartney 1 98 1 ; Perzigian and Widmer 1978; Clark etal. 1987). 
Paleopathological studies indicate a lack of probable tuber- 
culosis among highly mobile , broadly dispersed ( low-density) 
populations, but a wide range of disease incidence among 
more sedentary, village-living (high-density) populations. 

The variability in disease incidence among the latter 
groups approximates that of an epidemic wave in some areas, 
such as southern Ontario (Pfeiffer 1984). Thus, paleopathol- 
ogy has demonstrated the error of the earlier "virgin immune 
status" assumption, and has demonstrated that tuberculosis 
occurred prehistorically under the same kinds of environ- 
mental stresses that cause problems today: poor hygiene, 
crowding, and poor nutrition. This information is very rele- 
vant to the current debate regarding whether certain ethnic 
groups with high rates of infection are genotypically unique, 
with respect to HLA haplotypes, for example (Ottenhoff et 
al. 1986). This would appear to be a clear case of predictive 
relevance for paleopathology. However, in fairness one must 
add that the paleopathological evidence is not well known by 
nonanthropological researchers. 

Relevance of paleopathology to other 
metabolic conditions 



Relevance of paleopathology 
to infectious diseases 

Otitis media is a common affliction among the children of 
many Indian groups, and as many as one-third of the children 
in some Inuit villages have chronic infection of the middle 
ear (Brody et al. 1965). The condition, which can cause 
permanent hearing impairment, appears to be tied to bottle- 
feeding in infancy (Schaefer 1971 ), possibly exacerbated by 
a particularly short, straight eustachian tube (Timmermans 
and Gerson 1980). It seems improbable that paleopathologi- 
cal evidence could be gathered relevant to its prehistoric 
incidence, which should, indeed, be nil. However, study of 
the normal auditory bulla of native crania in comparison to 
those of other racial groups might help to explain why native 



The discussion thus far has not addressed the central group of 
contemporary maladies, the "New World Syndrome." Nor 
has it addressed certain ubiquitous skeletal conditions of pre- 
historic natives which seem not to pertain to contemporary 
health problems. 

Studies of cortical bone quality of prehistoric natives have 
frequently demonstrated low adult bone mass (Pfeiffer and 
King 1983; Mazess 1966; Thompson and Guinness-Hey 
1981) and relatively rapid rates of adult cortical bone loss 
(Ruff and Hayes 1983). 

Erickscn has summarized the results of several studies of 
North American Indian femora, all of which indicate an adult 
rate of loss greater than that seen in modem black or white 
groups. The calculation of a bone loss rate is dependent on 
accurate ages at death, and there is a tendency for most 

Zagreb Paleopathology Symp. 1988 



Is paleopathology a relevant predictor of contemporary health patterns? • 15 



skeletal estimators of age at death to underestimate the age of 
old adults. Hence, there is reason to question the common 
proposition that the amount of bone lost by modern groups 
from ages 20 to 90+ years was lost over only three or four 
decades in archeological native samples (Ericksen 1982). 
Nevertheless, measures of cortical thickness from such sam- 
ples show lower values than cither archeological black sam- 
ples or modem cadaver collections. PfciiTer and King (1983) 
studied femora, metacarpals, and lumbar vertebrae of pre- 
historic American Indians using a cross-sectional approach, 
and argued that mean adult values for all measures were 
below expected normal values. 

High incidences of vertebral compression fractures have 
been demonstrated among prehistoric lnuit(Merbs 1983) and 
Iroquoians (Pfeiffer 1984). Indeed, such compression frac- 
tures appear to be relatively common among all northern 
native skeletal samples in which they have been studied. 
Note that such samples are believed to represent primarily 
young adults, with very few survivors over age 55. 

This phenomenon of low cortical mass has been explored 
in modem Inuit populations. While initial study of Alaskan 
Eskimos suggested that these lower bone densities were tied 
to a high-protein, high-phosphate, low-calcium, sea mam- 
mal diet (Mazess and Mather 1974), subsequent studies of 
Canadian Inuit (Mazess and Mather 1975) and southern 
Alaskan Eskimos ( Harper et al . 1 984) show that the bone loss 
is not associated with a very specific dietary regime. Among 
these ;groups there is some variability in young adult peak 
bone mass, but all show an accelerated rate of bone loss with 
aging. Harper et al. note that, despite the potential, these 
Eskimo groups do not display a high incidence of osteoporo- 
tic fractures. They postulate that this might be due to short 
life expectancy. 

Among Indians, a small cross-sectional study of southem 
Ontario natives demonstrated significantly lower cortical 
bone density in postmenopausal Indian women (N = 34) than 
in postmenopausal white women (N = 43) (Evers et al. 
1985). However, no osteoporotic fractures had occurred 
among the Indian women (Evers, pers. comm.). There was 
no attempt to identify compressed vertebrae, which can func- 
tion as an early, asymptomatic indicator of osteoporosis. 

If low adult bone mass is a predictable characteristic of 
native populations, it may be relevant to predicting an in- 
crease in the incidence of senile osteoporosis as native life 
expectancy increases. Low peak adult bone mass has been 
observed for other Asiatic-origin populations, through both 
growth studies (Gam et al. 1964; Eveleth 1979) and adult 
radiographic screening (Nordin 1966; Yanoet al. 1984). De- 
pending on geographic location, Asiatics may show os- 
teoporotic fracture rates that are extremely low, or higher 
than those of whites (Wong 1966; Chalmers and Ho 1970). 
Certainly diet, intensity of physical work, and the presence 
of confounding diseases such as tuberculosis will influence 
the probability of fracture in these groups. Obesity has been 
demonstrated to have a protective effect, helping to maintain 

Zagreb Paleopathology Symp. 1988 



postmenopausal bone mass (Ribot et al. 1988). Many native 
populations currently show high weights for height (cf. Nu- 
trition Canada 1 980), and so may not experience the expected 
magnitude of postmenopausal bone loss. However, future 
public health measures are likely to emphasize weight re- 
duction as a generally desirable goal. Should populations 
achieve that goal, the paleopathological evidence of Native 
Americans is consistent with a prediction of a relatively high 
incidence of osteoporotic fractures as the contemporary pop- 
ulation ages. 

There is thus far no metabolic mechanism known to link 
low cortical bone mass to diabetes mellitus or any other 
component of the "New World Syndrome." Women with 
non-insulin-dependent diabetes may be at risk for bone loss, 
possibly because of the adverse effect of insulin deficiency 
on protein synthesis (Nordin 1983). Diabetics may also show 
high cortical bone mass (Meema and Meema 1967). Obesity, 
diabetes, and gallstones may all be directly associated with 
abnormalities in protein metabolism. Insofar as protein and 
calcium metabolism are interactive, consideration of a link 
with bone mass maintenance is not unreasonable. 

Population differences in endocrinological activity have 
not been oriented toward explaining differences in adult peak 
bone mass or rates of bone loss. However, apparent popula- 
tion differences in steroid control are consistent with ob- 
served pattems of bone mass acquisition and loss (Purifoy 
198 1 ). Blacks, who appear to tend toward a set point favoring 
an increased ratio of androgens to glucocorticoids, exhibit 
increased peak bone density, and frequently a slower rate of 
bone loss. Asiatics, conversely, show decreased androgens 
(both groups described relative to whites) and increased 
glucocorticoids. Such fundamental differences could explain 
the observed tendency toward lower peak bone mass in Asia- 
tics. 

Conclusions 

The contribution that paleopathology can make directly to 
the health of Native Americans is limited by the perspective 
of modem health sciences. When population dilTercnces in 
disease prevalence are associated solely with ethnic atTilia- 
tion, there is a tendency for researchers to look for behavioral 
or environmental causation, ignoring the more difficult mat- 
ter of genetic predisposition. The research necessary to iden- 
tify a racial or genetic component is extremely difficult to 
design, owing to the difficulty of identifying Mendelian pop- 
ulations in the past or present and the lack of information on 
the genetic basis of most diseases. Nevertheless, the ac- 
knowledged need for race-specific standards of child devel- 
opment plus acknowledged racial differences in morphology, 
physiology, and biochemistry will continue to push popula- 
tion health studies in this direction (Watts 1981). The quan- 
tification of contemporary native groups' genetic link with 
pre-European native populations will allow a clearer weigh- 
ing to be placed on paleopathological evidence. 



16 • Susan Pfeiffer 



This evidence has been used to some good effect to predict 
environmental conditions under which tuberculosis is likely 
to be most virulent. It could be used in a similar fashion to 
elucidate the etiology of other conditions such as otitis me- 
dia, congenital hip dysplasia, and low peak bone mass. Pal- 
eopathological evidence is consistent with preliminary ob- 
servations of low bone density in modern natives and is 
predictive of future osteoporosis. Finally, a retrospective 
study of bone metabolism through paleopathological evi- 
dence could be very helpful in understanding the metabolic 
pathway underlying the New World Syndrome. 

Thus, paleopathology can be of some predictive utility, 
and can help us improve the health of contemporary Indians 
and Inuit. It can be more useful in the future if: (a) a racial 
(biological) component is acknowledged where present and 
quantified in ethnic disease ditTerences, (b) paleopathologi- 
cal studies are designed with specific contemporary health 
problems in mind, (c) such studies are pursued using an 
epidemiological approach, and (d) paleopathologists convey 
their relevant knowledge directly to practitioners and health 
professionals. 

Acknowledgment 

This work benefited from comments offered by A. Herring 
and M. Mahaney, who read an earlier version of the manu- 
script. 



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Summary of audience discussion: There are limits of time and 
funding for research in paleopathology. Given those limitations one 
may question whether or nol it is realistic to develop an elaborate 
data protocol and research design as part of our research endeavors. 
If one cannot draw reliable conclusions from the published reports 
on palcopathological specimens, many of the really important ques- 
tions in paleopathology will not be answered. There is a threshold of 
content and quality that needs to be met or the published research is 
likely to be of minimal value. 

The establishment of general data protocols need not unduly limit 
the creativity of a researcher. There cannot be significant progress 
on many palcopathological problems unless there is a minimal base 
of reliable data that can be used in proposing generalizations and 
building theory. To do that will require generally accepted descrip- 
tive terms and a classificatory system that will allow us to at least 
count the number of cases in different categories. Furthermore, 
since lesions arc critical to classification, we must study every 
available bone for evidence of disease. That is a lot of work but there 
can be no paleoepidemiology if that is not done. 



Zagreb Paleopathology Symp. 1988 



On zoonoses and their relevance 
to paleopathology 



Don R. Brothwell 



During the process of preparing this paper, at least one 
national newspaper called attention to the concern of the 
British health authorities about a sheep disease which is at 
present affecting pregnant women. In farming areas in partic- 
ular, infection of sheep with a Chlamydia species not only 
causes abortion in sheep, but has posed a health problem for 
many women living near farms. It is interesting that this same 
genus of microorganism causes specific human conditions of 
the eye and lymphogranuloma venereum, although closely 
related parasites in rodents suggest that these are again zoo- 
noses, but with a longer history. 

What is zoonosis? One might have expected international 
agreement on such a commonly used term, but in fact this is 
not so. Zoonoses can simply be taken to be "diseases and 
infections transmitted naturally between vertebrate animals 
and man" (White and Jordan 1963). Alternatively, it can have 
the broader definition of a "disease of animals — as opposed 
to disease of man" (Fiennes 1967). Halpin (1975) believes 
the true meaning to be "a disease or infection shared by both 
animals and man." The implication here is that parasites can 
be shunted in both directions, and indeed it is known, for 
instance, that humans can act as a reservoir for Myco- 
bacterium bovis and reintroduce this parasite back into 
tuberculosis-free livestock. 

Perhaps the right emphasis is achieved by regarding hu- 
man groups as participants in "infection chains" (Schwabe 
1964), sharing certain infectious diseases with other genera 
for varying periods of time. As Aristotle and his world was 
aware of rabies as a zoonosis and even some Third World 
tribal groups understand certain disease links between spe- 
cies (the Masai realize that anthrax can be caught from con- 
taminated meat), the concept is likely to have had a long 
history. Without doubt the implications of zoonoses are rele- 
vant even to our study of the prehistory of disease. For we all 
too often consider human diseases in relative isolation (other 
than for the intrusive parasites themselves). So the zoonoses 
provide a focus for considering a continuum and evolution of 
diseases beyond the species level. 



Although more than one classification of the various zoo- 
noses has been elaborated, I do not wish to expand on the 
alternative classifications here. These are fully discussed in 
Schwabe (1964). My concern is to emphasize, in general 
overall terms, the importance of viewing human groups and 
their patterns of disease against an environmental back- 
ground in which there is "movement" of parasites over time 
through to the hominids. This mosaic of disease has a prehis- 
tory as long as that of the vertebrates. From our point of view, 
diseases are linked to the hominids in the following ways:(a) 
by adaptively following along the course of primate-hominid 
evolution;(b) by direct links between hominids and other 
vertebrates; during the Pleistocene, there must have been 
profound changes associated with greater reliance on hunt- 
ing;(c) the closer association of human groups with other 
species, especially domestic livestock, as a result of agricul- 
ture;(d) the development of high-density urban populations, 
with enhanced or continued association with other verte- 
brates;(e) the elaboration of cultural factors, from the keep- 
ing of pets and the long-distance transportation of exotic 
animals, to the improvement of hygiene. 

Has this kind of overall speculation about zoonoses any 
great relevance to paleopathology? I think it has, and there 
seems little doubt that anyone concerned with general issues 
of past disease ecology, or paleoepidemiology, should not 
ignore this subject. While zoonoses have received attention 
at meetings for over a century, and the first London meeting 
of the international Congress of Hygiene and Demography 
devoted a special section to it (Shelley 1892), anthropology 
and archeology have been remarkably slow to appreciate the 
importance of disease in biological and environmental stud- 
ies. Indeed, all aspects of the environment may be relevant to 
a reconstruction of suitable habitats for disease vectors. For 
example, the survival of the disease-carrying tick Ixodes 
ricinus in Europe depends on moisture and vegetational 
cover, and it is interesting to speculate on changes in its 
distribution with the spread of farming and expansion of 
permanent and well-managed pastures (detrimental to these 



18 



Zagreb Palenpalholojty Symp. 1 988 



On zoonoses and their relevance to paleopathology • 19 



ticks). Similarly, the survival of tsetse fly in Africa, and thus 
the transmission of trypanosomiasis, depends on the avail- 
ability of woodland or savanna. 

There is no doubt that there are many aspects of human 
disease, past and present, which will continue to benefit from 
a balanced consideration of zoonoses in relation to other 
aspects of human health. In an earlier largely agricultural 
society for instance, can we consider the apparent historic 
evidence for leprosy without also taking account of the possi- 
bility of confusion with. say. contagious pustular dermatitis 
(known as "Orf")? And should one evaluate Burkitt's lym- 
phoma and other conditions of uncertain etiology without 
taking into account that they may have resulted from a virus 
zoonosis? 

In terms of distances over which disease can be intruded 
into populations, birds are clearly a major group of rele- 
vance. Even today in Britain, their numbers exceed humans 
by two to one. and many are migrants. If they don't directly 
affect human groups, wild birds can transport numerous dis- 
eases to our domesticates (Keymer 1958). including anthrax, 
foot and mouth disease, and salmonellosis. The bird- 
mosquito- Japanese encephalitis link is perhaps one of the 
more complex epidemiologies in this respect (McClure 
1963). 

Parasite evolution and disease changes 

Viewing hominid diseases against a broader background of 
vertebrate diseases provides more opportunity for reflecting 
on the adaptive evolutionary changes which must have oc- 
curred in a variety of parasite species. Lambrecht (1967). for 
instance, provides a convincing reconstruction of the se- 
quence of events which could have resulted in the intrusion of 
trypanosomiasis from nonprimate mammals into hominids 
living in savanna biomes. Eventually, Trypanosoma rhodesi- 
enseAypt parasites evolved specifically in association with 
the hominids. Then, in post-Pleistocene times, the early pas- 
toralists moving south with their livestock were to be se- 
verely affected by "nagana" in their animals, other trypano- 
some species transferred by Glossina from reservoirs in wild 
mammal species. 

A very different evolutionary scheme is needed to explain 
the difterentiation of mycobacteria causing tuberculosis and 
leprosy in the vertebrates. While Grmek (1983) suggests that 
this parasite has a very long history of association with verte- 
brates, extending p)erhaps over 300 million years, he views 
the last 25,000 years as a critical period for the differentiation 
of varieties of tuberculosis and leprosy in mammals. But 
what ecological or other biological factors are responsible for 
this late microevolution is not easy to resolve. 

While the differentiation of human pathogenic mycobac- 
teria has received attention recently, further evidence of the 
possible rate of change which can occur in that group could 



be provided by paratuberculosis (Johne's disease). So far, 
only cattle and sheep appear to be infected. In northern Eu- 
rope, three types have been described, including a distinc- 
tive Icelandic form (Hungerford 1959). What is interesting 
from an evolutionary point of view is that the Icelandic vari- 
ety is only just over fifty years old, the disease carriers hav- 
ing been imported from Germany in 1933. The disease 
probably did not exist in the Icelandic sheep population 
before then, but within the first fifteen years 70,000 had 
been killed by it on the island (Halpin 1975). Has the dis- 
ease changed, or are Icelandic sheep sufficiently different 
('?genetically-immunologically) to determine the difference, 
or are environmental factors influencing the manifestation 
of the disease? 

A major problem in understanding parasite evolution and 
dispersal from a primary host to other species is that we don't 
know enough yet about potential host resistance. Shigella, 
for instance, is restricted in the number of mammal species it 
normally infects, yet it has been relatively successful in pri- 
mates (Fiennes 1978). Moreover, the virulence and often 
fatal nature of human shigellosis, caused by our own evolved 
pathogen Shigella dysentehae. suggests that it diverged rela- 
tively recently from the monkey parasite S. flexneri. Could 
this have been due to the closer association of hominids with 
a wide variety of other higher primate species as a result of 
increased hunting during later Pleistocene times? 

Zoonoses in relation to hunting, farming, 
and urbanism 

During hominid evolution, profound changes have occurred 
in terms of food resource exploitation and the development of 
urbanism. This is not the place to enter the debate on the 
actual antiquity of Pleistocene hunting, but food bone debris 
and butchery marks certainly suggest that hominids were 
widely hunting and becoming more closely associated with 
their prey (including meat processing and skin preparation) 
by at least half a million years ago. Compared with more 
herbivorous primates, this closer association with other 
mammals could have greatly assisted in establishing certain 
zoonoses in the hominids. 

Psittacosis (i.e., all types of ornithosis), for instance, 
would have been a potential danger to all those handling birds 
infected with the causative microorganisms (Beaudette 
1955). This disease is not restricted to parrots, and indeed 
pigeons arc now an important reservoir of the infection. An- 
other condition one could associate with increased hunting 
would be the tick-borne infection tularemia. Toxoplasmosis 
could have been a zoonosis of worldwide importance. While 
cats have probably been the most important group to carry 
these sporozoans. these days sheep and pigs are commonly 
infected. Poorly cooked meat would enable the infection to 
be passed on. In the indigenous South African hunter- 



Zagneb Paleopathology Symp 1988 



20 • Don R. Brothwell 



gatherer peoples, there is serological evidence of tox- 
oplasmosis in 6% to 27% of the groups studied (Nurse and 
Jenkins 1977). 

Was it also in the Pleistocene that tuberculosis expanded its 
horizons and became established in human groups? If so, was 
it a mutant o\' Mycobacteria hovis as generally believed, or 
could it have been derived from M. avium? What further 
questions should we be asking of these species in relation to 
M. tuberculosis to answer more satisfactorily the ancestral 
relationships of one with the other? In terms of posing a 
human threat, the development of dairying in association 
with some early urban societies would have greatly increased 
the chances of spreading bovine tuberculosis, of course, but 
this time span of five or six thousand years is surely too short 
to allow for the distinctive separation of the human tuber- 
culosis variety — or was it? 

It has to be kept in mind that in the past, as more recently, 
tuberculosis could be passed on from farm to farm by more 
mobile domesticates. Dogs are certainly capable of carrying 
the infection. They can also be a health threat in various other 
ways, of course, from rabies to the nematode Toxocara 
canis. Zoonoses can occur which are known to be established 
only in domesticates. Louping ill, of the central nervous 
system, is such a condition, and the virus can be transmitted 
to humans. 

It has been pointed out (Fiennes 1967) that, as a result of 
agricultural developments and urbanism, another possible 
change afl'ecting zoonoses was the exploitation and adapta- 
tion of various rodent species to crops and settlements. Evi- 
dence of the infestation of habitations is provided early in 
Egypt, as well as the actual evidence of mice from Catal 
Huyuk in Turkey (Brothwell 1981). Perhaps the most in- 
famous of the rodent-carried diseases is typhus, which even 
in this century has been highly destructive of human life. 
There seems little doubt that murine typhus was the early 
established primary disease and that by the increasingly close 
proximity of rodents to people (and the adopted parasite- 
transmitting role of human lice from rodent fleas), the classic 
human form of typhus evolved. So here we may well have a 
relatively new disease of only six thousand years or so. 

If on epidemiological grounds, Fenner(1971) is correct in 
stating that the viability of measles in a community depends 
on about 3000 cases a year in a population of 300,000, then 
this disease also was dependent on the emergence of larger 
neolithic groups and urbanism. We need to look then for an 
ancestor, and Fiennes (1978) suggests that of the pseudo- 
myxoviruses of the measles-distemper-Rinderpest triad, dis- 
temper could well have the greatest antiquity, extending back 
from domestic dogs to the wolf ancestor. However, measles 
could be relatively recent in this sequence of parasite micro- 
evolution, so should we again be viewing the human disease 
as only a few millennia old? 

Finally, as regards the impact of mammalian domesticates 



on human population health, it should be noted that accord- 
ing to the World Health Organization (1962), milk has per- 
mitted the transmission of over thirty distinct diseases, in- 
cluding a number mentioned here. The advent of dairying 
and its eventual wide distribution must then have made a 
further significant contribution to the spread of evolving zoo- 
noses. 

Zoonoses and the organic remains of humans 

So far, I have been discussing in general terms the impor- 
tance of considering zoonoses in relation to changing human 
disease patterns, societies and environments in the past. This 
may seem to be a somewhat theoretical matter to consider at a 
meeting specifically concerned with paleopathology. But of 
course ancient pathology is a step toward the reconstruction 
of changing disease ecologies through time, of paleoepide- 
miology. Also, the whole question of accurate diagnosis of 
pathology rests on a good knowledge of the disease alterna- 
tives which may have occurred within a particular environ- 
ment. As yet, there is a tendency to consider evidence of 
pathology somewhat in a vacuum, neglecting if not ignoring 
some disease ecology and the probability of microevolution 
in specific parasites (and consequent changes in disease ex- 
pression). 

To what extent, for instance, has histoplasmosis been con- 
sidered in the differential diagnosis of bone pathology? It 
may be considered uncommon enough today to escape atten- 
tion, but has it always been so? It can result in considerable 
skeletal pathology, especially the African form, caused by 
Histoplasma duboisii (Cockshott 1 96 1 ; Cockshott and Lucas 
1964), simulating to some extent metastatic deposits. New 
World morbidity evidence suggests that it can still be picked 
up from visiting caves, where the lloor may have bat feces 
containing histoplasma; indeed it is sometimes called "cave 
disease." As well as eventual bone changes, histoplasmosis 
more commonly produces lesions of the lung, and these may 
calcify (and could be confused with tubercular calcifica- 
tions). How often have the burials of cave dwellers been 
considered for this environmental problem? The answer is 
probably never, and the likelihood of the interior of the rib 
cages being carefully excavated for calcified masses is even 
more remote! 

Ortner and Putschar (1981) have rightly pointed out that 
glanders, primarily a disease of horses, can occasionally 
today cause human skeletal lesions. These could be confused 
with treponemal disease and to some extent leprosy (in skull 
and long bones), although the exact nature of the dry-bone 
pathology is not really known. There may also be infectious 
arthropathies, especially at the knee, elbow and ankle, a fact 
which on present knowledge is likely to be missed for what it 
is by rheumatologists concerned with arthropathies in the 
past. 



ZuRivh PiileopiUhology Symp. 1988 



On zoonoses and their relevance to paleopathology • 21 



While glanders is kept under relative control in most coun- 
tries today, and thus tew human cases would be expected to 
occur, this may not have been the situation in the past, and 
indeed serious horse "plagues" are known to have occurred in 
antiquity. The very considerable loss of horses by Charle- 
magne while fighting the Huns was possibly the result of 
glanders. To what extent this disease has changed in its de- 
gree of impact on human groups must remain for the present a 
matter of speculation, but this does not mean that the disease 
should be ignored in differential diagnosis. 

Perhaps one of the most interesting yet neglected of the 
zoonoses is brucellosis. Until early in the 1 9th century, it was 
not clearly ditTerentiated from malaria and certain other in- 
fections. The closely related species of Brucella are mainly 
but not exclusively pathogens of goats, cattle, and pigs (B. 
melitensis. B. abortus, and fi. suis, respectively). Although 
diagnosis in humans is often not easy to establish, neverthe- 
less it can clearly build up to large numbers of infected people 
(between 1945 and 1949 in the U.S.A. over 26,000 cases 
were recorded). Commonly, infection is transmitted to hu- 
mans via milk or cheese, but contaminated meat and even 
close proximity to livestock can significantly increase 
chances of infection (Dalrymple-Champneys 1960). 

It could be significant, in terms of how recent human 
groups became commonly infected, that skeletal changes do 
not normally occur in other mammals with brucellosis. Hu- 
man bone changes today occur in from 2% to 70% of infected 
groups, but could the average frequency have declined 
through time? The spine is particularly involved, and may 
show multifocal surface osteitis or cavitating abscesses or a 
"parrot beak spondylitis." In some of the vertebral changes as 
well as in other pathology, for instance in the articular bone 
rarefaction at the hip joint (Zammit 1961 ). the pathology may 
mimic that of tuberculosis (though vertebral collapse is not 
typical). The fact that joint involvement in other mammals is 
relatively mild and affects only the joint soft tissues could 
surely argue for a long adaptation time to Brucella, while the 
human pathology could suggest a more recent impact of the 
disease. As dairying has a prehistory extending back less that 
10,000 years, we may be viewing in the as yet very limited 
paleopathology, evidence of a relatively short adaptive mi- 
croevolution of brucellosis in human populations. There is 
certainly a need to keep this zoonosis in mind when consider- 
ing especially vertebral arthropathies and any pathology sug- 
gestive of early-stage tuberculosis. 

Conclusions 

Although disease in human groups can be viewed clinically 
in isolation, any broader view of these diseases in adaptive 
and evolutionary terms demands that we extend our perspec- 
tives to include social changes, environmental factors, and 
even other host species. Some diseases very probably 



evolved within the period of hominid evolution, but others 
may have primate or other mammal precursors. 

Sorting out these categories of disease in evolutionary 
terms demands that we be acquainted with zoonoses, not 
only those which leave their mark in ancient bones, but also 
those which contribute to the more theoretical aspects of 
studying ancient human diseases. This may perhaps seem to 
be teaching one's grandmother to suck eggs, but I for one 
confess to being all too forgetful of the degree to which 
human diseases are in fact zoonoses of very varying antiq- 
uity. 

It would be nice to think that we might eventually be able 
to contribute to a comparative paleopathology. A disease 
such as tuberculosis might yield to this in a decade or two. 
Moreover, now that sieving and flotation techniques are pro- 
ducing numerous small mammal bones from some sites, 
there is even the possibility of eventually solving the origins 
of leprosy. Murine leprosy can show incidences of between 
1% and 5% in wild rodents (Rankin and McDiarmid 1968) 
and presumably could have been brought into much closer 
contact with humans with the emergence of high-density 
urbanism. As yet, it is not conventional to look at rat and 
mouse bones for signs of bone inflammation which might be 
suggestive of infection by Mycobacterium lepraemurium. 
but this will eventually have to be done. 

Finally, mention should be made of the fact that there is 
clearly much progress in the field of helminthology in rela- 
tion to the past. Parasite eggs in particular promise to yield an 
increasing amount of information on certain zoonoses, some 
facts having particular relevance for human communities. 
For instance, Zimmerman ( 1980) records in his study of an 
ancient Alaskan Eskimo body that the intestinal tract con- 
tained eggs of the fish trematode Crypiocotyle linf>ua. Other 
genera of helminths which inhabit fish have also been de- 
scribed, and clearly indicated fishing and fish eating. With 
further studies of latrine residues and coprolite material, one 
hopes from earlier and earlier deposits, there is thus a chance 
that zoonoses will even provide extra information on diet. 



Literature cited 

Beaudclte. F.R.. ed. 1955. Psittacosis. Diagnosis. Epidemiology 

ami Control. New Brunswick. N.J.: Rutgers University Press. 
Brothwcll, D.R. 198 1 . The Pleistocene and Holoccnc Archaeology 

of the House Mouse and Related Species. In R.J. Berry, ed.. 

Biology of Hou.'ie Mouse. 1-1.^. London: Academic Press. 
Cockshott. P. 1961. Mycetoma. In H. Middlemiss, ed.. Tropical 

Radiology, .^8-53. London; Hcineniann. 
Cockshott. W.P.. and A.O. Lucas. 1964. Radiological l-indings in 

Histoplasma duhoisii Infections. British Journal of Radiology, 

.17:65.3-660. 
Dalrymple-Champneys. W. I960. Brucella Infection and Undulant 

Fever in Man. London: Oxford University Press. 



Zagrrb Paleopat/iology Symp. 1988 



22 • Don R. Brothwell 



Fcnncr, F. 1971. Infectious Disease and Social Change. Medical 
Journal of Australia. 1;I043, 1099. 

Fiennes, R. 1967. Zoonoses of Primates. London: Weidenfield and 
Nicolson. 

1978. Zoonoses and the Origins and Ecology of Human 

Disease. London: Academic Press. 

Grmek, M.D. 1983. Les Maladies a I'Aube de la Civilisation Occi- 
deniale. Paris: Payot. 

Halpin. B. 1975. Patterns of Animal Disea.se. London: Bailliere, 
Tindall and Cox. 

Hungerford, T.G. 1959. Diseases of Livestock. London: Angus and 
Robertson. Keymer. LF. 1958. A Survey and Review of the 
Causes of Mortality in British Birds and the Significance of Wild 
Birds as Disseminators of Disease. Veterinary Records, 70:7 1 3- 
720, 736-740. 

Lambrecht. F.L. 1967. Trypanosomiasis in Prehistoric and Later 
Human Populations, a Tentative Reconstruction. In D. Brothwell 
and AT. Sandison, eds.. Diseases in Antiquiry. 132-151. 
Springfield, 111.: Charles C Thomas. 

McClure, H.E. 1963. Birds and the Epidemiology of Japanese En- 
cephalitis. Proceedings of the 13th International Ornithological 
Congress, 604-610. 

Nurse, G.T.andT. Jenkins. 1977. Health and the Hunter-Gatherer. 
Monographs in Human Genetics. 8. Basel, Switzerland: Karger. 

Ortner, D.J., and W.G.J. Putschar. 1981. Identification of Patho- 
logical Conditions in Human Skeletal Remains. Smithsonian 
Contributions to Anthropology. 28. Washington. D.C.: Smithso- 
nian Institution Press. 

Rankin, J.D., and A. McDiarmid. 1968. Mycobacterial Infections 
in Free-Living Wild Animals. InA. McDiarmid, ed.. Diseases in 
Free-Living Wild Animals. 119-131. London: Academic Press. 

Schwabe, C.W. 1964. Veterinary Medicine and Human Health. 
Baltimore: Williams and Wilkins. 

Shelley, C.E., ed. 1892. The Relations of the Diseases of Animals to 



Those of Man. Transactions of the Seventh International Con- 
gress of Hygiene and Demography, London, 1891. London: Eyre 
and Spottiswoode. 

White, E.G., and F.T.W. Jordan. 1963. Veterinary Preventive Med- 
icine. London: Bailliere, Tindall and Cox. 

World Health Organization. 1962. Milk Hygiene. World Health 
Organization Monograph. 48. 

Zammit, F. 1961. Brucellosis. In H Middlemiss, ed.. Tropical 
Radiology, 54-60. London: Hcinemann. 

Zimmerman, M.R. 1980. Aleutian and Alaskan Mummies. In A. 
Cockbum and E. Cockburn, eds.. Mummies, Disease and An- 
cient Cultures. 1 18-134. Cambridge, U.K.: Cambridge Univer- 
sity Press. 

Summary of audience discussion: Morphologic bone alterations 
in a bacterially infected host occur only if host resistance is suffi- 
cient to allow survival over a period long enough to allow produc- 
tion of the destructive and responsive skeletal changes. The routine 
absence of such changes in viral infections, together with the need 
of at least the more virulent viruses for a large, nonimmune popula- 
tion to maintain them, suggests that viral infections are more recent 
and therefore may have played a lesser role in the evolutionary 
history of infectious diseases. Some interesting recent reports sug- 
gest that viral agents may trigger erosive arthropathies and there 
may be a relationship of distemper to Paget's disease. 

A thorough search of ancient North American bison bones could 
make a major contribution to the question of whether bovine tuber- 
culosis in the New World preceded or followed the human form. 
Tuberculosis could have developed in zoonoses in very early peri- 
ods, been lost, and emerged again in later zoonoses. We also need 
more precise information of brucellosis-generated bone changes so 
we may search for them in archeological samples and trace the dairy 
product-linked diseases. 



Zagreb Paleopathology Symp. t9fiH 



Tuberculosis and leprosy: Evidence for 
interaction of disease 



Keith Manchester 



Leprosy and tuberculosis are chronic infective diseases of 
mankind, caused by bacteria of the genus Mycobacterium. 
Tuberculosis is not solely a human disease, but is also en- 
countered in lower mammals, in birds, and in certain cold- 
blooded animals. In contrast, although a leprosy-like disease 
has been identified in chimpanzee and in "wild" armadillo, as 
an important and relevant epidemiological entity it is essen- 
tially a human disease. Historically, on current evidence, 
both infections are relative newcomers to the spectrum of 
human disease. Perhaps more than any other disease in hu- 
man history, leprosy has generated strong social reaction, 
which persists overtly or as undercurrent in many parts of the 
world today, has stimulated legislation, and given rise to 
abhorrence. These emotive aspects of disease have spanned 
many centuries. The reactions at epidemics of plague were, 
undoubtedly, of greater intensity, but these were short-lived 
and, in themselves, were epidemic. It is likely therefore that 
the manifold reactions and opprobrium of leprosy were due 
to the chronicity of the disease, its mutilating and pitiful 
presentation, and to ill-founded theology. But, to what extent 
this last was a reactive root is not known; Christian and non- 
Christian medieval communities both practiced segregation 
and demonstrated ambivalence of attitude, harsh and benefi- 
cent, toward the leprosy sufferer. Tuberculosis was the sub- 
ject of Touching for the King's Evil in the European Middle 
Ages, but little other public reaction was engendered. In 
terms of mortality, tuberculosis was the "Captain of all the 
men of death." 

Bacteria of the genus Mycobacterium are responsible for 
more human suffering and misery than any other bacteria. 
Both tuberculosis and leprosy are eliminated as serious 
health problems in Western Europe and yet. in past centuries 
both were of immense significance therein. Today both arc 
still of immense significance in many parts of the world, 
particularly the tropics and subtropics. In Western Europe, 
the increasing eradication of tuberculosis is due largely to 
improved socioeconomic conditions and, more particularly, 
to prudent public health measures. Eradication of bovine 
tuberculosis, mass immunological screening of juveniles, 
and appropriate vaccination are eliminating the disease. The 

Zagreb l^leopaihology Symp. 1988 



demise of tuberculosis is, therefore, due to human agency. 
Not so with leprosy. The changing patterns in leprosy preva- 
lence and in clinical intensity have been, and to some extent 
still are, totally independent of any human activity directed 
toward control and eradication. 

This paper seeks to review the history of tuberculosis and 
leprosy in antiquity and to consider the historic changing 
patterns within the concept of modern epidemiology and 
immunology. 

Bacteriology 

The bacteria responsible for the human diseases of leprosy 
and tuberculosis are members of the genus Mycobacterium. 
This genus, which contains about 30 species, is characterized 
by the ability of the bacilli to retain staining by fuchsin and 
related bacteriological stains in the laboratory after exposure 
to weak acids. This acid-fast property is not, however, 
unique to the mycobacteria. Of greater genus specificity and 
taxonomic value is the nature of the lipids within the bacterial 
cell walls. It is likely that the virulence or pathogenicity of 
each species is intluenced by the specific lipid content. It is 
also likely that the host immunological response to invasion 
by the bacteria is infiuenced by the lipid content. 

Of all the mycobacterial species, M. leprae is unique in 
that it is not possible, with present laboratory methods, to 
culture the bacterium in vitro. As a pathogen, its natural host 
is mankind, although, as noted, a leprosy-like disease has 
been recorded in chimpanzee and armadillo. Antigenically. 
M. leprae has been shown to be related to M. vaccae. an 
environmental saprophyte (Grange 1980:30). An evolution- 
ary significance of this finding has not, as yet, been demon- 
strated. 

M. tuberculosis, in common with all other mycobacteria 
except M. leprae, is culturable in vitro. M. tuberculosis is. 
however, unique among the culturable mycobacteria in pos- 
sessing no environmental saprophytic strains. It is an obli- 
gate pathogen. Many of the other culturable mycobacteria 
may be responsible for disease in man or animals, and Col- 
lins and Grange (1983:18) remark that not all mycobacteria 

23 



24 • Keith Manchester 



isolated from clinical material are tubercle bacilli. Such bac- 
teria may be regarded as opportunist pathogens. 

At present, there is not total agreement on the taxonomy of 
the bacilli causing tuberculosis in man and in cattle. One 
taxonomic opinion regards the responsible mycobacteria as 
separate species, M. tuberculosis, M. bovis, and M. afri- 
canum. Alternatively, these are considered to be variants of 
the single species M. lubenulosis. and there are noted to be 
five recognizable variants of this species (Collins and Grange 
1983:19). Differentiation, regardless of taxonomic debate, is 
based on in vitro growth characteristics, aerobic status, and 
enzymatic properties (Grange 1980:22; Collins and Grange 
1983: 17), but differentiation into these separate strains has no 
clinical value. 

However, while the dialectic of taxonomy may be relevant 
to the evolution of tuberculosis as a human disease, the im- 
munity induced by infection by the various bacilli is common 
to them all. 

Immunology 

The basis of host defense against infection is twofold: innate 
nonspecific immunity, and acquired specific immunity. 

Natural or innate immunity is not directed at any specific 
invading organism. It is of multifactorial component and 
consists of biological host factors such as secretory and me- 
chanical barriers to invasion by pathogens, bactericidal prop- 
erties of body fluids, phagocytic cellular activity, and deter- 
minants such as general health and nutritional status, age, 
and hormonal balance (Weir 1986:42-44). It is thus depen- 
dent upon the milieu inteheur. In socioeconomically unsta- 
ble archaic communities this innate immunity must surely 
have played an important role in the epidemic and endemic 
infections of antiquity. This is mirrored today, perhaps, in the 
famine and war-torn peoples of the Third World, and the 
attendant endemic and fulminating epidemic infections. 

But it is the second immune mechanism which is of partic- 
ular interest in M. leprae and M. tuberculosis interrelation- 
ship. This is the acquired mechanism of adaptive immunity, 
characterized by memory, specificity, and the recognition of 
"non self" (Roitt 1980:1). The recognition of non self is 
axiomatic and refers to the specific antigens, in the present 
case M. leprae and M. tuberculosis. Memory too is implicit; 
exposure to the specific pathogen (antigen) induces long- 
term host protection to future infection and development of 
clinical disease. Specificity in the immune response depends 
principally upon the host synthesis of antibody (immu- 
noglobulin) to a specific antigen and its release into the blood 
and other body fluids. This is the very basis of humoral 
immunity. There is no evidence that humoral immunity plays 
any significant role in the defense mechanisms against my- 
cobacterial infection. It is another distinct acquired immune 
mechanism which is active in mycobacterial infection: cell 
mediated immunity (CMI). M. leprae and M. tuberculosis 
are intracellular facultative parasites inducing, ipso facto. 




LEPROMATOUS 



TUBERCULOID 



Figure 1 . The spectrum of immunity and clinical disease in 
leprosy. (After Jopling 1982:296) 



pathological change and clinical disease. Upon invasion of 
the body, the mycobacteria are ingested by phagocytic cells 
(macrophages), and the bacterial intracellular faculty stimu- 
lates action by T lymphocytes. The stimulated T lympho- 
cytes produce and release a biologically active molecule 
called lymphokine. Within this group of substances are fac- 
tors which influence the activity and movement of mac- 
rophages. The macrophage so influenced produces a greater 
intracellular content within itself of lysosomal enzyme. This 
increased enzyme content heightens the ability of the mac- 
rophage to kill intracellular parasites contained within it. 
This, the basis of CMI, and considered very superficially 
here, is complex when applied to A^. /cprac infection with the 
broad immune, and consequent clinical spectrum. In tuber- 
culosis, host immunity is absolute; clinical response to infec- 
tion is not dependent upon and modified by a gradation of 
immunity, either innate or acquired. By contrast, it has been 
demonstrated (Ridley and Jopling 1966; Jopling 1982:296) 
that there is a spectrum of host immunity to M. leprae infec- 
tions, and it is the status of the individual within this spec- 
trum which determines the severity and type of clinical dis- 
ease, and its infectivity, within the individual (Figure 1 ). The 
concept has also been applied in paleopathology (Andersen 
1982:223). At one end of the spectrum is the state of absence 
of immunity, that is, low resistance to the pathogenic effects 
of invasion by M. leprae. The resultant clinical disease is 
lepromatous leprosy, a multibacillary condition charac- 
terized by high infectivity. At the other end of the spectrum is 
the state of high immunity, or high resistance to the pathogen. 
In this state the clinical disease is tuberculoid leprosy, 
paucibacillary and of low infectivity. There is gradation of 
clinical presentation and infectivity between these extremes. 
Indeed, beyond the high-resistant tuberculoid end of the 
spectrum lies the concept of subclinical infection, a state of 
noninfective bacterial presence within the host, but without 
pathological manifestation. Paleopathologically, the low- 
resistant, lepromatous or near lepromatous state is uniquely 
differentiated by its development of rhinomaxillary change 
(Andersen 1982:223). It is a reality, dependent upon such 

Zugrel) Paleopalhology Symp I'iHS 



Tuberculosis and leprosy: Evidence for interaction of disease • 25 



factors as pregnancy, intercurrent infection, and malnutri- 
tion, for an infected individual of relatively high resistance 
type of leprosy to downgrade toward the lepromatous pole. 
This concept of immune spectrum is of epidemiological im- 
portance and is of significance in the history and develop- 
ment of leprosy. 

However, the immunity in the cell mediated response is 
not absolutely specific. Mackaness (1967:337) has demon- 
strated that the simultaneous exposure of /W. titherculosis and 
another bacillus, Listeria monocytogenes, to a host sen- 
sitized by previous exposure to M. tuberculosis induces im- 
munity to both pathogens. The lone exposure of L. mono- 
cytogenes to the M. tuberculosis-sensiiiicd host does not, 
however, induce immunity. It is the dual and coincident ex- 
posure which is significant in immunity induction. To what 
extent this duality of exposure and immunity applies in M. 
leprae and M. tuberculosis in clinical context is not, at pres- 
ent, known. If the same conditions apply as in M. tuber- 
culosis and Listeria invasion, then there may be relevance to 
human exposure and immunity in the medieval period in 
Britain when both infections were present and when tuber- 
culosis was of increasing incidence. 

A further response of CMI, of diagnostic significance in 
tuberculosis and of pathological tissue significance in both 
leprosy and tuberculosis, is delayed hypersensitivity reac- 
tion. This reaction in which granulomata, lesions typical of 
leprosy and tuberculosis, are induced, is not considered sig- 
nificant in the present discussion of bacterial interrelation- 
ship. 

Within the context of immunity, prophylactic immuniza- 
tion by Bacille Calmette Guerin (BCG) is relevant to tuber- 
culosis and to leprosy. BCG, produced from M. hovis. is used 
in clinical circumstances to induce immunity to tuberculosis 
in persons demonstrated by Mantoux hypersensitivity testing 
to be nonimmune to the infection. The phenomenon of BCG 
immunization does, itself, demonstrate the phenomenon of 
mycobacterial cross specificity, since the vaccine is not pro- 
duced from M. tuberculosis but is produced from M. bovis. a 
subspecies or variant. In clinical trials in areas of the world in 
which leprosy is endemic, BCG immunization has a proven, 
but variable, efficacy in the prevention of leprosy. The range 
of variability is from 20% efficacy in a Burmese trial to 80% 
efficacy in Uganda. Fine ( 1984: 147) suggested a number of 
reasons for this variability. Differences between these popu- 
lations exhibiting such diverse BCG efficacy may, in part, be 
attributable to a degree of immunity to leprosy acquired by 
contact with environmental mycobacteria. Administration of 
BCG vaccine to a people already in possession of such partial 
immunity may merely augment the overall population immu- 
nity to leprosy, and indeed to tuberculosis also, thereby 
falsely overestimating the value of BCG vaccination. 

In summary, the acquired defensive mechanism in tuber- 
culosis and leprosy is CMI. The immune reaction is not 
absolutely pathogen specific, but a degree of cross immunity 
between the pathogens is noted. Delayed hypersensitivity 

Zagreb Paleopathology Symp. 1988 



reaction is of significance in the development of post primary 
tuberculosis and probably in the granulomatous development 
in leprosy. Genetic immunity is of unknown, but probably 
little, significance in leprosy and tuberculosis. Innate immu- 
nity is a nonspecific entity and is dependent upon biological 
adaptive mechanisms in the host to environmental and meta- 
bolic change and to intercurrent infection. 

There is no evidence to suggest that the bacteria responsi- 
ble for the clinical diseases of leprosy and tuberculosis were 
in any way different in antiquity from those of today. Neither 
is there evidence to indicate that the immunological mecha- 
nism of the host to bacterial invasion has changed through 
time. 

It is temporal change in the immunological status of popu- 
lations, modified by previous bacterial exposure, which is, in 
part, the basis of the present hypothesis. 

Epidemiology 

Because, in the main, tuberculosis and leprosy are diseases 
of the undeveloped and developing nations, in which statis- 
tics are either absent or unreliable, the prevalence of these 
diseases in the world at the present time is not known. It is 
estimated, however, that there are 1 1 .5 million cases of lep- 
rosy (World Health Organization 1985:10), although it is 
suggested (Andersen 1987) that the figure may be nearer to 
20 million. The total number of persons with tuberculosis is 
not known, but it is estimated that 10 million persons develop 
tuberculosis each year and at least 3 million die of the disease 
(World Health Organization 1982:10). 

Against this stark statistic it is necessary to consider as- 
pects of the epidemiology of these two diseases. Much of the 
data are determined from current practice with only minimal 
input from paleopathological studies. Because, as osteoar- 
cheological evidence indicates, there has been no change in 
host tissue response to infection by M. tuberculosis or M. 
leprae, and there has, thereby, been no change in clinical 
presentation through time, it is considered justifiable to ex- 
trapolate current epidemiological data to archaic popula- 
tions. The inherent risks in moving from the known to the 
unknown are accepted. 

TRANSMISSION AND DEVELOPMENT 

There are, essentially, two portals of entry of the organisms 
causing tuberculosis in man: ingestion of bacilli or inhalation 
of bacilli. Reference to the taxonomic debate on A/, bovis and 
M. tuberculosis has already been made, and the irrelevance 
of this in immunology is noted. However, in terms of trans- 
mission, and in the context of a hypothesis of historic devel- 
opment of disease, the two bacilli, be they strains or species, 
are of significance. Transmission of M. bovis is via the gas- 
trointestinal tract from the ingestion of cattle meat or milk 
infected with M. bovis. The primary tuberculous lesion is 
therefore in the gut. Transmission of M. tuberculosis is via 



26 • Keith Manchester 



the respiratory tract from inhalation of droplets infected by 
M. tuberculosis and exhaled by a person with open, infec- 
tious, pulrnonary tuberculosis. The primary lesion is there- 
fore in the respiratory tract, either tonsillar bed or, more 
commonly, lung. Because of this mode of transmission, pul- 
monary tuberculosis may be considered to be a population 
density-dependent disease (v.i.). 

The incubation period, that is the latent interval between 
implantation of bacillus and the development of clinical dis- 
ease, in tuberculosis is long. Dependent upon the course of 
development of tuberculous infection, the incubation period 
may vary from two years to several decades. In terms of 
immunity, these figures are largely meaningless and depend 
upon interpretation of clinical disease. The first manifesta- 
tion of infection, termed primary tuberculosis, consists of an 
infected lesion at the site of entry of bacilli, and associated 
infective change in regional lymph nodes. This state, which 
may be without clinical symptoms, is associated with the 
development of immunity to further infection. Thereafter, 
and dependent upon such other factors as general health sta- 
tus, there may be complete resolution of the primary complex 
but with maintenance of immunity. Survival of the individual 
and restoration of total health ensues. The end result is a 
healthy person immune to tuberculosis and, in some mea- 
sure, to other mycobacterial diseases. Alternatively, the pri- 
mary infection may progress as a disseminated, fulminating, 
and fatal disease with distant organ involvement or miliary 
lesions. Whatever the mortal presentation, these individuals 
are removed from the scene of population immunity and are, 
therefore, irrelevant to the present discussion. Those individ- 
uals surviving the primary lesion and restored to health may, 
at some future date, subject to a deterioration of general 
health status or to the development of intercurrent infection. 
develop progressive tuberculous disease. This post-primary 
or secondary infection may be the result of reactivation of 
quiescent primary lesions, or the result of reinfection by the 
pathogenic organism. The difficult differentiation in the 
etiology of post-primary tuberculosis between reactivation or 
reinfection is of significance epidemiologically and may be 
of significance in the history of the disease. The endogenous 
or exogenous .source of bacilli is of no significance in the 
clinical course of the disease or in immunological status. 
Post-primary infection is the familiar disease of adulthood, 
characterized pathologically by progressive granulomatous 
and caseating lesions, and clinically by progressive emacia- 
tion, cough, dyspnea, and hemoptysis in pulmonary disease 
and abdominal pain, distension, and pyrexia in gastrointesti- 
nal disease. Subsequently, other organ involvement may en- 
sue, and bone and joint infection are of major importance in 
osteoarcheology. 

To repeat and stress however, it is the primary infection in 
tuberculosis, with tuberculin conversion indicating immu- 
nity, which is of significance in the immune profile of the 
surviving individual and, through his place therein, of the 
population as a whole. 



After many years of uncertainty, it has now been demon- 
strated that the clinically important mode of transmission of 
M. leprae is by inhalation of infected droplets from a leprous 
individual harboring bacilli in his nasal mucosa (Jopling 
1982:295). Transmission of leprosy is, therefore, largely 
from individuals with multibacillary disease, that is, those 
from the low-resistant end of the immune spectrum. The 
criteria for such infectivity is the presence of a "highly 
bacilliferous nasal discharge" (Pedley and Geater 1976:97). 
The infectivity of paucibacillary. tuberculoid leprosy is 
slight. In contrast to earlier thought, it is now considered that 
leprosy, from Icpromatous cases, is a highly infective dis- 
ease, but that, because of the immune status, only a small 
proportion of people infected with the bacillus actually de- 
velop clinical disease. 

The incubation period of leprosy is. like tuberculosis, of 
uncertain and long duration, probably between two and sev- 
en years (Jopling 1982:296). 

Unlike tuberculosis, the pathogenesis of leprosy is not 
biphasic. There is no primary and secondary complex in 
leprosy. As previously noted, M. leprae is an intracellular 
pathogen, and has an affinity for Schwann cells of peripheral 
nerves and for cells of the reticuloendothelial system. After 
infection, tissue change and consequent clinical disease is 
progressive, modified only by the immune status, and 
change therein, of the host. Although, as yet. the stage of 
development of acquired immunity in leprosy is incom- 
pletely understood, it has been demonstrated by immunolog- 
ical testing in Micronesia and Sri Lanka that an immunity has 
developed from three months to two years before the onset of 
clinical disease (World Health Organization 1985:23). 

Leprosy, unlike tuberculosis, is generally not a fatal dis- 
ease. It is a relentlessly progressive and mutilating disease, 
but further discussion of the clinical symptoms and signs of 
the disease is beyond the scope of this paper. 



AGE 



In tuberculosis, the development of CMI is coincident with 
the pathological changes of primary infection. Tuberculin 
sensitivity is a codevelopment of CMI. albeit associated with 
antibody production, itself of little significance in the tuber- 
culous defensive mechanism. Tuberculin sensitivity conver- 
sion can however be taken as a guide to the acquisition of 
immunity and, as a corollary, to the period of primary infec- 
tion. Unfortunately, the age of conversion is incompletely 
known for modem developed nations and is almost com- 
pletely unknown for undeveloped nations. It follows, by na- 
ture of the evidence, that the age of conversion can never be 
known for archaic peoples. Neither, of course, can it be 
known for more recent peoples before the advent of tuber- 
culin sensitivity testing. Some other guide to primary infec- 
tion, appropriate, by extrapolation, to archaic peoples must 
be used. 

If the death rate from tuberculosis, by year of death, is 

Ztij^reb Paleopathology Symp. I98H 



Tuberculosis and leprosy: Evidence for interaction of disease • 27 



examined from the prechemolherapeutic era, it is noted (Fine 
1984: 14 1 ) that the highest mortality occurs before the age of 
five years, failing dramatically thereafter and rising again 
markedly in the third decade (Figure 2). This may be inter- 
preted as a high infant mortality associated with primary 
infection and a further high and sustained mortality with 
fwst-primary infection, if these late 19th century data can be 
assumed representative of medieval populations, then initial 
exposure to M. nihcnulosis and the development of primary 
infection and consequent immunity occurred during infancy. 
Because the ELISA test for leprosy infection is a relatively 
recent introduction which has not. as yet, had a wide applica- 
tion in epidemiology, age patterns in leprosy can be deter- 
mined only in relation to clinical disease. The age of in- 
fection and, in consequence, the age of development of 
immunity, are unknown. However, the age of infection is, 
post hoc propter hoc, dependent upon the age of contact of an 
individual with an infective case. It is also dependent upon 
the intimacy of contact (v.i.). In infected families young 
children are likely to have more intimate contact than older 
individuals, and therefore the young are more likely to be- 
come infected (Badger 1964:84). Clinical disease is rarely 
encountered below the age of five years. The incidence then 
rises to a plateau in the fourth decade. With acceptance of the 
long and variable incubation period, it seems likely that the 
age of infection in leprosy may be somewhat later than that 
for tuberculosis. Thus the age of development of acquired 
immunity may, likewise, be somewhat later. 



700- 



600- 



500- 



o 
o 

o 



cr 

LlJ 
Q- 



a: 

I 
< 



200 



100- 




20 



30 40 50 60 70 



AGE AT DEATH 
(IN YEARS) 

Figure 2. Tuberculosis death rates by year 
of death, late 19th century, Massachusetts. 
(After Fine 1984:141) 



SEX 

Although variations according to age and sex in incidence 
rates of both tuberculosis and leprosy as clinical diseases are 
known, it is considered that the sex variation has little bear- 
ing on the proposed immunological interrelationship. Further 
analysis is, therefore, not relevant within this paper. 

POPULATION DENSITY 

Leprosy has been described as a "disease of the villages" 
(Hunter 1986:5). But against this generalization, there is 
considerable evidence that household contacts of patients 
with lepromatous disease are at a high risk of infection. 
Epidemiological studies in Burma, South India, and the Phil- 
ippines has indicated a familial clustering of infection (World 
Health Organization 1985:23-24). It is noted (Badger 
1964:72) that the more intimate the contact the greater the 
risk of infection, and the risk of infection is greater with 
intrafamilial than with cxtrafamilial contact. In keeping with 
this, the rate of infection is also influenced by the number of 
contacts to whom an individual is exposed. Such interpreta- 
tion of familial susceptibility is also complicated by the influ- 
ence of socioeconomic status, hygiene, nutrition, and a "ge- 
netically determined susceptibility" of blood relatives. 
Studies suggest that there is an association between crowding 

Zagreb Paleopalhology Symp. 1988 



and leprosy, but the problems of poverty and mobility of 
peoples further complicate the picture. The inhalation mode 
of transmission of A/, leprae suggests that crowding of peo- 
ples and intimacy of contact are important epidemiological 
factors. Therefore, it is expected that leprosy is a disea.se of 
village and urban communities alike. 

Buikstra and Cook ( 1 98 1 : 1 1 8) described tuberculosis as a 
population density-dependent disease, and Cockbum ( 1963:88) 
also considered the disease to be a crowd disease of urban 
society. However, with regard to the different modes of trans- 
mission of M. bovis and M. tuberculosis and, in conse- 
quence, to the diHerent primary manifestations and immu- 
nity therefrom, the relation, in immunological perspective, 
of infection to pt)pulation density may be twofold. Primary 
gastrointestinal disease caused by M. bovis is dependent 
upon human contact with an animal reservoir of tuberculous 
beast. Herd size, not human population size, is the critical 
factor for cndemicity of human primary gastrointestinal tu- 
berculosis (Manchester 1986). Thus, this disease is likely to 
atTect urban and rural peoples alike, assuming the general 
availability of milk and flesh. The growth of markets in 
medieval towns and cities in Britain is likely to favor urban 
exposure. Pulmonary tuberculosis is, in contrast, entirely 



28 • Keith Manchester 



dependent upon contact with a fellow human with open in- 
fectious disease. Pulmonary tuberculosis is, therefore, a 
crowd disease of population density dependence. It is, of 
course, possible, particularly within the confmes of the com- 
munal animal-human ionghouse, for pulmonary infection via 
inhalation of M. hovis to develop from intimate contact with 
an "open" cattle infection. It is further acknowledged that 
post-primary infection, irrespective of primary focus, may 
be achieved by ingestion or inhalation. But, as already 
stated, it is the primary infection, and the immunity devel- 
oped thereby, which is significant to the arguments of this 
paper. It is proposed therefore that, in antiquity, there was a 
baseline of M. bovis primary infection which was sporadic 
and totally independent of human population size. In addi- 
tion, as primary disease, and superimposed as post-primary 
disease, there was M. tuberculosis infection. This was de- 
pendent upon population density, and followed and was a 
con.sequence of urbanization and aggregation of peoples in 
trade. It is unfortunate but, notwithstanding the pulmonary 
tuberculous interpretations of rib lesions by Kelley and 
Micozzi (1984), paleopathological differentiation of pulmo- 
nary and gastrointestinal disease cannot, as yet, be made. 
The above comments on the archaic implications of M. bovis 
and M. tuberculosis have not, therefore, been investigated or 
proven. 

SOCIOECONOMY 

Both tuberculosis and leprosy are diseases associated, in 
general terms, with poverty, poor nutrition, and poor general 
health status. Badger (1964:73) remarks that, in leprosy, "the 
greatest prevalence has been, and remains, among peoples of 
low economic status, with inadequate housing etc., which 
leads to crowding and intimate contact." In the paleopathol- 
ogy of tuberculosis, a demonstration of these factors has yet 
to be made. In the paleopathology of leprosy, M0ller- 
Christensen (1978: 1 17) reported that 69.7% of leprous skel- 
etons from Naestved exhibited cribra orbitalia, while only 
20.2% of contemporaneous nonleprous skeletons from 
<€beIholt exhibited the lesion. The work of Stuart-Macadam 
(1982) has indicated that cribra orbitalia is the manifestation 
of anemia in infancy. The inference therefore from M0ller- 
Christensens findings is that the leprous inmates of the 
Nifistved leprosarium were from an anemic, nutritionally de- 
prived section of medieval society. The possibility of chronic 
intestinal parasitic infestation in infancy contributing to this 
anemia may also suggest a poor general health status and 
level of poverty. Further work on cribra orbitalia, porotic 
hyperostosis, and latrine deposits of medieval lazar houses is 
needed. 

History 

Although, within the remit of this paper, it is necessary to 
consider only those regions in which leprosy and tuberculosis 



were coexistent in antiquity, it is appropriate to review the 
earliest history and development of these two infectious dis- 
eases of mankind. The development and prevalence of en- 
demic infectious disease within a species may have relevance 
to a developing innate immunity and to acquired immunity 
within a population. 

Both leprosy and tuberculosis are relative newcomers to 
the spectrum of human disease, and tuberculosis, in historic 
terms, is the older of the two. 

TUBERCULOSIS 

The earliest evidence of tuberculosis as a human disease is 
from the fourth millennium B.C., and consists of osteological 
and iconographic specimens. A Neolithic skeleton of this 
period from Italy exhibits spinal osteolytic lesions compat- 
ible with a diagnosis of osseous tuberculosis (Formicolaetal. 
1987). A figurine exhibiting angular kyphosis and features 
suggestive of the cachexia of advanced consumption has 
been described from fourth millennium Egypt (Morse et al. 
1964). Other pre-Dynastic figurines with angular kyphosis 
are known, but documentary records from the early Near 
East do not contain descriptions suggestive of tuberculosis. 
The Semitic Code Laws of Hammurabi of Babylon, the 
Ebers Papyrus (Mercer 1964), and the medical Papyri (Cave 
1939) do not record disease compatible with tuberculosis. 
Further eastern Mediterranean examples of skeletal tuber- 
culosis are known (Ortner 1979), and from the first millen- 
nium B.C. tuberculosis has been identified in mummified 
remains from Egypt. 

Further east, documentary records suggestive of tuber- 
culosis are found in India of second millennium B.C. date, 
and Mesopotamia of first millennium B.C. date. Suzuki 
(1985) has described skeletal lesions from protohistoric 
Japan. 

Although not within the discussion of this paper, it is of 
interest and probable historic significance that the earliest 
world evidence of animal domestication is from the eastern 
Mediterranean, some three millennia before the earliest 
world evidence of tuberculosis. 

Away from the Mediterranean littoral, the earliest Euro- 
pean evidence of tuberculosis is a skeleton exhibiting spinal 
lesions of Potts' disease, and dated to third/second millen- 
nium B.C. from Denmark (Sager et al. 1972). A Neolithic 
skeleton from Heidelberg has also been diagnosed as tuber- 
culous on recognition of possible spinal lesions (Bartels 
1907), but doubt has recently been cast on this diagnosis. 

However, for the purposes of this paper examining a possi- 
ble relationship between leprosy and tuberculosis, it is appro- 
priate and necessary to consider in detail only one geographic 
area where the two diseases coexisted and in which their 
history is adequately known. For these reasons and for the 
convenience of the author, detailed examination of the later 
history will be confined to Britain. It is acknowledged, of 
course, that this somewhat blinkard microcosmic view is one 

Zagreb Falecpiitholotty S\mp. I9S8 



Tuberculosis and leprosy: Evidence for interaction of disease • 29 



of convenience and that the evidence, constraints, and hy- 
potheses could equally be drawn from other regions of the 
world in which the two diseases coexisted in antiquity. 

Probably the earliest evidence of tuberculosis in Britain is 
of Roman date from Cirencester (Wells 1982:181; Manches- 
ter and Roberts 1987). During the succeeding centuries, the 
prevalence of tuberculosis increased, upon the evidence of 
skeletal specimens (Manchester and Roberts 1987). Unfortu- 
nately it is impossible from skeletal evidence alone to assess 
the absolute prevalence of the disease. The diagnostic criteria 
for tuberculosis in skeletal remains are woefully inadequate, 
the disease being diagnosed only at an advanced stage of 
osseous involvement. The rate of skeletal involvement in 
relation to the overall prevalence of tuberculosis in antiquity 
is not known, and it is not justifiable to assume, unequivo- 
cally, that this was the same in antiquity as it is today, al- 
though this is likely. Neither is it possible at present from 
osteoarcheological specimens to determine the primary site 
of involvement, pulmonary or gastrointestinal. 

During the reign of Edward the Confessor, a ritual was 
introduced for the cure of King's Evil. King's Evil was the 
name applied to cervical lymphadenitis. Although cervical 
lymphadenitis is of multiple etiology, tuberculous lymph- 
adenitis secondary to initial tonsillar or pulmonary infection 
was a prominent cause in the prechemotherapeutic era. Tu- 
berculous cervical lymphadenitis is traditionally equated 
with King's Evil. It may be significant, in epidemiological 
terms of primary site involvement, that this practice was 
introduced at the very time that urban development was a 
phenomenon and when movement of peoples in market trad- 
ing was becoming established. Clearly, Touching for the 
King's Evil was of no anti-infective therapeutic value what- 
soever, but the practice was probably of considerable spir- 
itual and psychological benefit to the recipient, to say noth- 
ing of his or her financial improvement thereby! Introduction 
of this practice in England, and also in continental Europe at 
a similar time, around the late lOth or early 1 Ith century, 
suggests that the disease was widely known, of increasing 
incidence, and sociocconomically significant. During the ad- 
vancing Middle Ages, the practice continued and the number 
of patients touched increased. 

By the mid 17th century it was recorded in the London 
Bills of Mortality that, in years free of plague, 20% of all 
deaths in the city were due to consumption (Clarkson 
1975:39). Although there was no knowledge of bacteriology 
and no autopsy confirmation of diagnosis, the clinical fea- 
tures of advancing tuberculosis were doubtless known. Pro- 
gressive untreated pulmonary tuberculosis, alternatively 
known as consumption or phthisis, presents with intractable 
cough, dyspnea, hemoptysis, and progressive emaciation. 
There can have been little confusion with nontuberculous 
pneumonia, and it is unlikely that carcinoma of the bronchus 
was a common disease. It is probable therefore that tuber- 
culosis was, indeed, a common cause of death in 17th cen- 
tury urban centers. 

Zagreb Paleopathology Symp. 1988 



In terms of polity there was, in contrast to leprosy, no 
segregation of the consumptive. Tuberculous individuals do 
not exhibit the physical mutilations of leprosy, there are no 
religious overtones associated with the disease, and presum- 
ably the infective nature was not suspected. Therefore, the 
expansion of medieval hospitals (v.i.) cannot be taken as 
evidence of an increasing incidence of tuberculosis. Neither 
was there legal enactment in respect of tuberculosis. 

It is unfortunate that the evidence for an increase in inci- 
dence of tuberculosis during the advancing Middle Ages is 
circumstantial, based on documents and traditions which do 
not provide irrefutable proof of the disease. However, as 
mentioned, in current paleopathological practice, the os- 
teoarcheological diagnosis of tuberculosis is mainly made on 
the spinal changes at an advanced stage of pathogenesis, at 
which caseous destruction of vertebral bodies and subse- 
quent collapse has occurred. Earlier stages of the disease are 
rarely recognized and, as yet, diagnostic criteria for early 
lesions have not been established. Within the framework of 
constraint it has been remarked, in respect of prehistoric 
Amerindian peoples that "if a contagious disease like tuber- 
culosis was present in overcrowded prehistoric populations, 
. . . then there should be many more cases than there have 
been found to date" (Morse 1978). Such statements reinforce 
the overwhelming need to establish criteria for the diagnosis 
of skeletal tuberculosis at early stages of pathogenesis in 
osteoarcheological contexts. Also, because the osteomyelitic 
and septic arthritic lesions in tuberculosis are metastatic 
changes from the initial site, it is not possible to establish the 
incidence and changing pattern of primary pulmonary and 
primary gastrointestinal tuberculosis. Such a facility would 
be of immense value in the paleoepidemiology of the disease. 
The considerations of rib lesions by Kelley and Micozzi 
( 1984) may be a pointer in this differentiation, but the lesions 
described and also observed by Manchester and Roberts 
(1987) are probably the sequel of empyema which may have 
causes additional to pulmonary tuberculosis. 

Notwithstanding these constraints of evidence, it seems 
certain that tuberculosis as a human disease was present in 
Britain at least by the Roman period, that it increased in 
prevalence throughout the Anglo-Saxon period, and that the 
incidence rate increased further during the post-Norman 
Conquest period. The disease did not effectively become 
controlled until the introduction of sanatoria and, particular- 
ly, the advent of antituberculous chemotherapy in the 20th 
century. 

The rising incidence rate in the post-Norman Conquest 
period may be related to urban development and to popula- 
tion movement and aggregation consequent upon regular 
market development in the medieval period. A detailed ex- 
amination of these paleodemographic changes is beyond the 
scope of this paper, but, in similar vein, it is noted by Allison 
(1979) that tuberculosis in Peruvian mummies was associ- 
ated, in increasing prevalence, with the development of ur- 
ban centers. 



30 • Keith Manchester 



LEPROSY 

The earliest evidence of leprosy is often quoted as facies 
leontina represented by a Canaanite jar from Beth-Shan, Pal- 
estine, dated to mid second millennium B.C. (Yoeli 1955). 
However, this jar is not considered representative of leprosy 
(Manchester and Zias, n.d.)but is, it is proposed, a portrayal 
of negroid facial features. 

There is literary record, displaying obvious clinical acu- 
men, of significant symptoms and signs of lepromatous lep- 
rosy in Sushruta Samhita (Dharmendra 1947:425-429), 
dated to 600 B.C. This, the earliest acceptably authentic evi- 
dence, indicates that the disease existed in India by the mid 
first millennium B.C. For a disease to have been so notewor- 
thy to have been recorded in literature, it is likely, in antiq- 
uity, that it was present in the community for some consider- 
able time previous. Rastogi and Rastogi (1984:541) have 
suggested that the word "kustha," mentioned in Indian litera- 
ture in the 15th century B.C., denotes leprosy. However, this 
reference is without clinical description and is based on im- 
precise social attitudes toward a disease, the nature of which 
is uncertain. It is not justifiable, therefore, to attribute M. 
leprae infection to this reference. 

From the second century B.C. , a terra cotta figure has been 
considered representative of leprosy (Grmek 1983:232). 
Also of third century B.C. date, a Chinese Bamboo Book 
contains a description of physical signs and symptoms which 
are compatible with a diagnosis of leprosy (Skinsnes 1980). 

As yet , the earliest skeletal evidence of leprosy in the world 
has been recorded from the Dakhleh Oasis, Egypt. Skeletons, 
of reputed European morphological type, have been diag- 
nosed as leprous on rhinomaxillary change (Dzierzykray- 
Rogalski 1980). Professor Rogalski's suggestion is that these 
skeletons, a minor component of a larger negroid nonleprous 
cemetery, represent European individuals segregated from the 
Greek colonial center because of their disease . If this sugges- 
tion is valid, then such a policy of ostracism may indicate the 
presence of leprosy in the Mediterranean littoral for many 
years prior to the date of the cemetery at Dakhleh Oasis in the 
second century B.C. This may be compatible with a new 
disease appearing in Greece at about the third century b.c. and 
described by Straton, a physician of the Alexandrian School. 
Andersen (1969:45) suggests that leprosy may have been 
brought to the Mediterranean area from India by the returning 
armies of Alexander the Great, but this view is considered to 
be, perhaps, too simplistic. Passage of peoples from the Far 
East to the Near East was, surely, a phenomenon for many 
years at that time, and it is not necessary to attribute the 
transference of leprosy to such a precise event. 

Further evidence of leprosy has been recorded in two Cop- 
tic mummies from Nubia. These specimens, dated to a.d. 
500 exhibit peripheral skeletal and rhinomaxillary stigmata 
pathognomonic of lepromatous leprosy (M0ller-Christensen 
and Hughes 1966). 



From the seventh century a.d.. skeletons exhibiting 
|X)stcranial and rhinomaxillary changes of leprosy have been 
identified in the ossuaries of Byzantine period monasteries of 
the Judcan Desert (Zias 1985). 

From northern Europe, the earliest evidence of leprosy is 
discovered in skeletal remains from Poundbury, Dorset 
(Reader 1974). The skeletal remains, dated to the fifth cen- 
tury A.D. of late Romano-British context, consist of the lower 
legs and feet only, the sole fragments archeologically avail- 
able for study. Although the absence of upper limbs and 
cranium for study reduces the validity of diagnosis, and 
doubt has been cast on this (T. Molleson, pers. comm. 1987), 
it is considered that, in differential diagnosis, leprosy is the 
most likely. 

During succeeding centuries leprosy became widespread 
and of increasing prevalence throughout northern Europe and 
lands of the Mediterranean littoral, as attested by art form, 
literary, and skeletal evidence (Andersen 1969; Gladykow- 
ska-Rzeczycka 1976; Grmek 1983:227-260; Manchester 
1981; Manchester and Roberts 1987; M0ller-Christensen 
1967; Skinsnes 1972; Wells 1962,1967). 

As in the discussion of the history of tuberculosis , it is only 
necessary, for this paper, to discuss in more detail the history 
of leprosy in Britain. 

Although the skeletal evidence of leprosy in post-Norman 
Conquest Britain is less profuse than in contemporaneous 
Scandinavia, a reflection of the research of Professor M0ller- 
Christensen, the overall development and change, temporal 
and geographic, of leprosaria in medieval England is as well 
known as in any other European country. As has been dis- 
cussed, the history of tuberculosis is also as well known 
in the period of disease contemporaneity as in any other 
country. 

Unlike the study of other diseases, and unlike the study of 
leprosy in earlier centuries, the prevalence and change there- 
in of leprosy in post-Norman Conquest Britain cannot be 
assessed from the isolated study of osteoarcheological re- 
mains. This is because segregation of leprosy sufferers in this 
period was certainly general, although not exclusive, policy. 
Leprous skeletons are found therefore in the cemeteries of 
leprosaria and less so in the cemeteries of nonlazar houses, 
monastic communities, and parish churches (Manchester and 
Roberts 1987). Thus, a diminishing number of leprous skel- 
etons in nonlazar house cemeteries after the Norman Con- 
quest must not be taken as indicative of a decline in the 
prevalence of the disease at this time. An assessment of 
leprosy prevalence and incidence can only be made by com- 
posite study of skeletal remains, lazar house foundations and 
development, lazar house records, and legal enactments. 
Such a multidisciplinary study is, at present, only in its in- 
fancy. 

A gross numerical analysis, century by century, of record- 
ed leprosaria in Britain shows a marked increase in their 
number during the period from the 11th to 13th centuries 
(Roberts 1986). In broad terms, the trend demonstrated by 

Zagreb Paleiipathology Symp I98fi 



Tuberculosis and leprosy: Evidence for interaction of disease • 31 



the figures is correct, and documented foundation dates are. 
in many cases, probably true foundation dates. However, 
there remains the possibility that the first literary mention of a 
lazar house may. erroneously, be construed as its foundation 
date, which may. in reality, have been many years previous. 
Neither should it be assumed that an observed rate of increase 
in lazar house foundations in unit time represents a similar 
arithmetic increase in the number of leprosy sufferers. No 
account is taken in these gross figures of lazar house founda- 
tions of the actual size of individual houses. To use a modem 
analogy, no account is taken of "bed state," no assessment of 
potential occupancy by leprosy sufferers is made. During the 
post-Norman Conquest years a religious fervor was develop- 
ing, one outlet of which was the demonstration of personal 
conscience, piety, and wealth, outwardly manifest as the 
foundation and endowment of hospitals in the medieval 
period. It is noted, therefore, that not only is there an increase 
in lazar house foundations, but there is a similar increase in 
nonlazar house establishments (Roberts 1986). 

Notwithstanding these constraints of interpretation, the 
increase in leprosaria and the legal enactments, royal dic- 
tates, and comments all indicate that leprosy as an endemic 
disease did increase in prevalence during the first three cen- 
turies after the Norman Conquest. 

The rate of increase of lazar house foundations, or literary 
mentions, seems to have been maximal during the 12th and 
early 13th centuries, reaching a peak during the 13th century. 
Thereafter, foundations, although continuing, declined 
markedly. In the 16th century only four new houses were 
founded, three in the southwest of England and one in East 
Anglia (Richards 1977:83). As with the increase in founda- 
tions, so with the decline; this cannot be taken, in isolation, 
as a direct arithmetic indication of a declining incidence of 
leprosy. There is a decline in foundations of nonlazar hospi- 
tals, although this phenomenon postdates the lazar house 
decline by a century or so. This event for both may represent 
changing attitudes toward endowment, social changes conse- 
quent upon the decline of feudalism, or maybe a preoccupa- 
tion with the ravages of the Hundred Years War and the Wars 
of the Roses. Additional documentary evidence does, how- 
ever, indicate that the disease declined by the 15th century. 
The house of Sherbum was so reduced from an establishment 
of 65 leprosy sufferers at foundation in 1181 to two by 1434. 
By the mid !6th century Sherburn housed no lepers at all. 
Similar circumstances were recorded in this period at Ripon, 
Shrewsbury, and Ilford. It is unfortunate that there is, as yet, 
no osteoarcheological evidence to support this phenomenon 
of decline. The sole reason for this absence of evidence is 
that, hitherto, no significant excavation and postexcavation 
analysis of lazar houses and their cemeteries has been under- 
taken in Britain. The stratigraphic demonstration, by archeo- 
logical excavation, of a declining number, through time, of 
leprosy skeletons in lazar house cemeteries would indeed be 
noteworthy. 

Zagreb Paleopathology Symp. 1988 



Thus, it is reasonable to conclude that leprosy, as an en- 
demic disease in Britain, was present at least by the late 
Roman period, increased steadily in incidence during the 
Anglo-Saxon and post-Norman Conquest period, reaching 
its zenith during the 1 3th century or so. Thereafter the disease 
declined and, except for pockets of isolation to a later century 
in southwest England and in northern Scotland, virtually 
disappeared by the 16th century. 

What is not known, and would be so interesting epi- 
demiologically, is whether there was any shift in the immu- 
nologically determined type of leprosy during its period as an 
endemic disease in Britain. Browne has suggested that lep- 
romatous leprosy was the only type of leprosy of significance 
in antiquity. In this endemic infectious disease, one may 
theorize that the decline in prevalence may have been associ- 
ated, post hoc propter hoc. with an increasing immunity and 
shift to the tuberculoid end of the spectrum. Although the 
presence of rhinomaxillary change in a skeleton is unequivo- 
cal evidence of lepromatous leprosy, the absence of this 
change is not a contraindication to this diagnosis. It may be 
that the individual of antiquity died before the develop- 
ment of the specific skull changes. In Professor M0ller- 
Christensen 's researches at Njestved ( 1 96 1 ), nasal inflamma- 
tory change was found in 100%^ of skeletons with peripheral 
osseous stigmata of leprosy. Anterior nasal spine change was 
found in 76.2%, and alveolar process of maxilla change in 
66%. This high proportion of rhinomaxillary change, per- 
haps as high as 100% of leprous skeletons, indicated the 
overwhelming prevalence of lepromatous disease in the lep- 
rosy sufferers of Nsstved. There was no stratigraphic. and 
therefore no chronological , differentiation of the skeletons at 
Nasstved. The prevalence of lepromatous disease is assumed 
to be constantly high throughout the period 1 250- 1 550 when 
Nasstved leprosarium was active. However, this does not 
affirm that the immunological pattern of the disease was 
universally constant throughout this period. Bone change 
pathognomonic of leprosy was found in 70% of the excavated 
skeletons at Naestved. This is much higher than the rate of 
involvement of bone in modem leprosy studies. The implica- 
tion of this finding is threefold: the rate of bone involvement 
may have been higher in leprosy in antiquity than it is today; 
the modem figures may be clouded by therapy relatively 
early in the clinical course of disease, and such therapy was 
clearly not a feature of antiquity; that only the most severely 
affected leprosy sufferers, those with mutilating osseous 
change, were segregated in antiquity. There is no evidence, 
as yet, for the first two propositions. There is, however, 
evidence for the last proposition. M0ller-Christensen discov- 
ered a leprous skeleton from his excavations at /Ebelholt 
(1953:13-14), and Manchester and Roberts (1987), and 
Henderson (1985) have discovered leprous skeletons from 
Norton Priory and Guildford Friary. These sites are not asso- 
ciated with established medieval leprosaria. It is enigmatic 
however that these "extramural" skeletons exhibit advanced 
rhinomaxillary features of lepromatous disease. If the last 



32 • Keith Manchester 



proposition is correct, and more research is obviously neces- 
sary, then the high Naestved presence of lepromatous disease 
may not reflect the overall population immunological trend 
in the Middle Ages. The leprous population not segregated 
may have developed a shift, through time, toward the high- 
resistant end of the immunological spectrum. In so doing, by 
a reduction in the rate of bone involvement, the very evidence 
necessary in paleopathology may be nonexistent. The further 
hypothetical implication for infectivity in antiquity will be 
explored. 



Interpretation 

Tuberculosis and leprosy are diseases which coexist in many 
underdeveloped countries of the world today. Within the time 
scale of modem epidemiological observation, there has been 
little change in their natural prevalence, and there has not 
been any comparative change in incidence rate, one disease 
against the other. Analysis of tuberculosis and leprosy, sepa- 
rate and intercurrent, in individuals has suggested that there 
is no relationship between these two infectious diseases in 
mankind (Chaudhuri and Ghosh 1975:302). The essentially 
epidemiological research of these two workers examines the 
disease status of patients at a specific time. The data do not. 
and indeed cannot in the absence of a predetermined immune 
status, identify to which pathogen, M. luherciilosis or M. 
leprae, the host was first exposed. Contrary to earlier opin- 
ion, it is now known that there is no increased susceptibility 
in lepromatous leprosy to tuberculosis (Jopling 1982:305). 
Tuberculosis has been, however, a major cause of death in 
modem leprosaria. Although there are immunological im- 
plications of this fact, the main reason for the high number of 
tuberculous deaths in leprosaria probably lies in the environ- 
ment with the facility for respiratory transmission of M. tu- 
berculosis. 

While epidemiology examines these two diseases and the 
changing pattems thereof through decades, paleoepidemiol- 
ogy examines through centuries. Precision in epidemiology, 
even with the constraints of Third World data, is obviously 
greater than in paleopathology, and in archaic contexts can 
never be complete. The multitude of environmental, social, 
biological, and therapeutic factors that inlluenced changing 
patterns of disease in antiquity can never be fully known. 
There must, therefore, be an element of surmise and calcu- 
lated guesswork in the interpretation of disease in antiquity. 

It is clear, as has been demonstrated (v.s.). that tuber- 
culosis and leprosy coexisted, at least for many centuries, in 
British antiquity. It is clear also that leprosy, as an endemic 
disease, declined and disappeared in the high Middle Ages, 
while tuberculosis continued unabated into modem times. 

Leprosy, as a di.sease of single mode of transmission, dem- 
onstrates prevalence and incidence rates which are dependent 
upon population density, intrapopulation contact, intimacy 
of contact, and economic status. The increasing prevalence 



during the Anglo-Saxon period and, particularly, the early 
Middle Ages, is due to increasing population, to increasing 
population density, and to increasing contact between peo- 
ples. As a natural disease per se, it is expected that the preva- 
lence of the early Middle Ages would be maintained or even 
increased during the later Middle Ages. This is demonstrated 
to be not so. 

It is suggested that tuberculosis, a disease of animal and 
human host, and a human disease of two modes of transmis- 
sion, was a biphasic human disease. In the earlier phases of 
tuberculosis history in Britain, it was a primary gastrointesti- 
nal disease by M. bovis transmitted from infected cattle. In 
the pre-urban era of low population density village society, 
tuberculosis was a sporadic disease. Therefore, a significant 
reservoir of immune, that is, tuberculin positive, population 
did not exist. Ikwueke (1984:1357) proposes that a new dis- 
ease in a community is relatively vimlent and tends to affect 
young generations. It is likely therefore that, in this first 
phase of development, many of the tuberculous individuals 
with primary gastrointestinal disease died, thereby removing 
them from the immune pool. 

It is further suggested that, with increasing population, 
mobility of peoples, and urbanization, there was a biological 
adaptation of the tubercle bacillus to a respiratory mode of 
transmission. The increased population density, increased 
contact between peoples, and, perhaps, reduced hygienic 
standards, developing, pari passu, with urbanization, fa- 
vored a widespread population exposure to M. tuberculosis. 
In antiquity, just as today, primary tuberculous infection oc- 
curred in young children. According to the concept of disease 
aging in the community (Ikwueke 1984:1356). there is a 
gradual decline in the severity of disease during its historic 
presence in mankind. Therefore, although many young 
children probably succumbed to the primary infection, many 
more survived with their consequent acquired immunity, 
manifest today by tuberculin sensitivity conversion . It is sug- 
gested that the urbanized population during the advancing 
Middle Ages became, in increasing numbers, immune to 
tuberculosis. Although village inhabitants had gradually de- 
veloping contacts among themselves and with urban dwellers 
through market trading, the increasing incidence of tuber- 
culosis may have been slight relative to the urban com- 
munity. There may also have been a higher proportion of M. 
bovis infection relative to M. tuberculosis in the village, but 
this is of no significance in individual tuberculous immunity. 

How far then may the coexistent developments of tuber- 
culosis and leprosy in the medieval period in Britain be seen 
as independent entities, and how far may they be considered 
to demonstrate an interaction of infectious disease according 
to modem immunological concepts? 

INDEPENDENT CHANGE 

Similarities of bacterial form and properties of M. tuber- 
culosis and M. leprae have been discussed. The respiratory 

Zagreb Pateopaihology Symp. 1988 



Tuberculosis and leprosy: Evidence for interaction of disease • 33 



mode of transmission is common to both infections, although 
the additional mode of gastrointestinal tuberculosis is distinct 
to the tubercle bacillus. Pulmonary tuberculosis and leprosy 
are, therefore, diseases dependent for their transference upon 
{wpulation density and intimacy of contact. Both diseases are 
more common in socially and economically disadvantaged 
groups: they are. in the main, disea.ses of the poor. 

Thus it is expected that those factors, significant in the 
epidemiology of the two diseases, would influence infection 
by M. tuberculosis and M. leprae in the same direction. For 
example, in the absence of other influences, a deterioration 
or improvement in the socioeconomic status of the popula- 
tion would be expected to produce, respectively, an increase 
or a decrease in the incidence rates of both tuberculosis and 
leprosy. Increasing population density would be expected to 
favor increasing incidence rates of both diseases. 

But, in spite of these common influential factors, the two 
diseases did not move in parallel in British antiquity. The 
increasing prevalence of both diseases during the late Anglo- 
Saxon and early post-Norman Conquest periods has been 
outlined, but the continued increase of tuberculous preva- 
lence and the simultaneous and rapid decline of leprosy in the 
later Middle Ages is a major fact. 

Ikwueke has proposed ( 1984: 1357) that in the concept of 
aging disease, there is a gradual decline in severity, and that 
disease eventually declines and dies. This phenomenon is 
proposed in the absence of effective therapy. From the cen- 
turies of coexistence in antiquity, osteoarcheological and 
documentary evidence does not support the tenet of declining 
severity in tuberculosis and leprosy. Within the constraints of 
archeological stratigraphy already considered, there is no 
paleopathological evidence to suggest that leprosy, during its 
period of epidemiological decline, declined in severity. But 
in this context it is acknowledged that a decline in severity, 
that is, a "population upgrade in immunity" from lep- 
romatous to tuberculoid leprosy, may be accompanied by a 
gradual disappearance of pathognomonic bone change. 
Thus, an absence of osteological evidence of severity decline 
may not be truly evidence of absence. This problem remains 
unresolved. The corollary of the decline in severity proposed 
by Ikwueke is the decline and disappearance of the disease. It 
is true, of course, that both diseases have declined in Britain, 
and that leprosy has disappeared as an endemic disease. The 
decline of tuberculosis was, however, a phenomenon of the 
post-Industrial Revolution era, even before the advent of 
antituberculous chemotherapy, whereas leprosy decline was 
some 500 years or so previous and was a much more rapid 
phenomenon. Was, perhaps, segregation a factor influencing 
this medieval decline of leprosy? It has been noted that the 
incubation period of leprosy is long, during which time there 
are no clinical manifestations to warrant segregation, and 
during which time the infected individual was, himself, in- 
fectious. As a preventative of transmission, segregation was 
clearly of limited value because the practice was akin to 
"shutting the stable door when the bacterial horse has 

Zagrrb Pahopaihotogy Symp. 1988 



bolted." Also, as noted (v.s.). segregation of infected indi- 
viduals in the medieval community was not absolute. 

Genetic immunity is of unknown, but probably little, sig- 
niflcance in tuberculosis and leprosy. Ikwueke comments 
(1984:1357) that there is growing evidence which makes 
transmission of acquired features a feasible proposition. 
How far this is applicable to immunity is unknown. 

An equally vexed problem is that of genetic susceptibility 
to the two diseases. Fine (1981:452) remarked that there is 
evidence, albeit contentious, for some role of genetic factors 
in determining responses in leprosy and tuberculosis, al- 
though a "major role of genetic polymorphisms in determin- 
ing epidemiological patterns" is unconvincing. Thus, al- 
though there may be some genetic influence in the initial 
setting of an individual on the immune spectrum in leprosy, it 
is doubtful if genetic factors are an influence, ah Initio, in the 
susceptibility of individuals to infection by M. tuberculosis 
or M. leprae. 

INTERACTION 

As already discussed, immunity in both leprosy and tuber- 
culosis is cell mediated, and antibodies have been considered 
unimportant, although in leprosy this matter is under review 
(Harboe 1981:5-6). The cell mediated immunity is not abso- 
lutely pathogen specific, as indicated in the varying response 
to infection by M. leprae following prior inoculation with 
BCG. 

The concept of cross immunity between leprosy and tuber- 
culosis was examined in depth by Chaussinand ( 1 948 . 1 950), 
and by Lowe and McNulty (1953). Chaussinand's proposals 
are based on epidemiological observations of the two dis- 
eases in Africa. India. Indochina, and Japan. Immunological 
evidence in support of cross immunity is outlined earlier in 
this paperfv.i. j. Consideration of cross immunity in relation 
to the history of the two diseases in mankind has also been 
made by Steinbock (1976:197-198), Grmek (1983:291- 
306), Manchester (1984), and Clark et al. (1987:50-51). 

What support then does paleocpidemiology afford to the 
concept of cross immunity and interaction of disease? 

It is suggested that, within the village-orientated and rela- 
tively isolated communities of the sub-Roman and Anglo- 
-Saxon periods, tuberculosis was of primary gastrointestinal 
focus due to M. bovis. Infection was sporadic and overall 
population immunity was insignificant. Both leprosy and 
tuberculosis smoldered unabated. Toward the end of the 
Anglo-Saxon period, townships and markets developed. 
These aspects developed particularly with the Norman and 
later towns and cities. Population density, consequent upon 
this development, prompted respiratory transmission of A/. 
tuberculosis. The introduction of Touching for King's Evil, 
an indication of droplet transmission, is in support. Crowd- 
ing of peoples facilitated the widespread urban, and to a 
lesser extent rural, exposure to the tubercle bacillus. Then, as 
in more modem context, the primary infection was probably 



34 • Keith Manchester 



in the young below the age of five years. Those infants 
surviving the primary infection were, in consequence, tuber- 
culin positive and had "lifelong" immunity to tuberculosis. 
As noted, the age of exposure toM. leprae is, even today, not 
known, but it is suggested that, epidemiologically. this may 
be at a somewhat older age than M. tuherculosis exposure. 
Thus, exposure to M. leprae may have been, in the popula- 
tion as a whole, to a people already immune to tuberculosis 
by previous primary infection. The protection afforded there- 
by may have prevented the establishment of clinical leprosy, 
except in those individuals whose immune response was 
compromised by poverty, malnutrition, or intercurrent dis- 
ease. Any improvement in these features during the advanc- 
ing Middle Ages would favor the development of an immune 
population. Furthermore, as has been noted, the simultane- 
ous presentation of M. tuberculosis and M. leprae to a person 
sensitized by previous exposure to M. tuberculosis may pre- 
vent the development of both infections. In communities in 
which both di.seases were common, such simultaneous ex- 
posure may, indeed, have occurred. 

Furthermore, in those individuals who developed clinical 
disease, the immunity conferred by prior exposure to M. 
tuberculosis may have caused a "right shift" along the 
Ridley-Jopling spectrum toward tuberculoid leprosy. This 
clinical manifestation of M. leprae infection is associated 
with relative noninfectivity. Thus, this diminution in leprous 
population infectivity may have contributed to the eradica- 
tion of the disease. 

It is possible therefore that the rapid decline of leprosy 
from a population in which the more virulent disease of 
tuberculosis was both widespread and increasing may be 
paleoepidemiological evidence of a cross immunity between 
the two diseases. 

The coexistence and increasing prevalence of the two dis- 
eases took several centuries to develop. The decline of lep- 
rosy, consequent upon and subsequent to the increasing prev- 
alence of tuberculosis, likewise took several centuries to 
occur. Modem epidemiological studies of these two dis- 
eases, influenced as they are by effective therapy, lack the 
prolonged time dimension which only paleopathology, pa- 
leoepidemiology, and medical history can supply. 

Disease is not solely a phenomenon of the modern world, 
to be studied only in its 20th century context. Disease has a 
past, it has a present, and will have a future. No one facet 
should be studied in isolation and ignorance of the others. 



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Illinois State Museum. 
Morse, D.. D.R. Brothwell, and P.J. Ucko. 1964. Tuberculosis in 

Ancient Egypt. American Review of Respiratory Disease. 

90:524-543. 
Ortner, D.J. 1979. Disease and Mortality in the Early Bronze Age 

People of Bab edh-Dhra, Jordan. American Journal of Physical 

Anthropology. 51:589-598. 
Pedley, J.C, and J.G. Geatcr. 1976. Does Droplet Infection Play a 

Role in the Transmission of Leprosy? Leprosy Review. 47:97- 

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Cambridge, U.K.: D.S. Brewer. 
Ridley. D.S., and WH. Jopling. 1966. Classification of Leprosy 

According to Immunity. A Five-Group System. Internatiimal 

Journal of Leprosy. 34:255-273. 
Roberts, C. 1986. Leprosy and Leprosaria in Medieval Britain, 

MASCA Journal. 4:15-21. 
Roitt, I.M. 1980. Essential Immunology. 4th edition. London: 

Blackwcll Scientific Publications. 
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Book in China. International Journal of Leprosy. 48:333. 

Steinbock, R.T 1976. Paleopathological Diagnosis and Interpre- 
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Stuart-Macadam. PL. 1982. A Correlative Study of a Pal- 
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Weir, DM. 1986. Aids to Immunology. London: Churchill 
Livingstone. 

Wells, C. 1962. APossibleCaseof Leprosy from a Saxon Cemetery 
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Summary of audience discussion: The immune status as defined 
by the skin tuberculin test has only a minimal influence on suscep- 
tibility to infection with contraction of clinical tuberculous disease, 
but it is the dominant factor in determining the form of the infection. 
A nonimmune individual is more apt to develop the rapid and often 
lethal course of tuberculous pneumonia or hematogenous spread of 
"miliary" tuberculosis, while the contained form of the disease 
(usually restricted to the lung) is more apt to occur in the tuberculin- 
positive ("immune") person. In the United States the death rate fell 
dramatically during the century preceding 1960, unaffected by the 
laboratory identification of the tubercle bacillus, isolation of pa- 
tients in sanatoria, or specific chemotherapy (the latter available 
only about the final 10 years of the period) Furthermore, except for 
the final decade, most people during that period were tuberculin- 
ptjsitivc by age 18. Neither the immune status nor therapy appears to 
have been responsible for the straight-line decline. More probable 
contributions include a reduction in the "dose" (i.e.. number of 
inhaled organisms) secondary to reduction in crowding and better 
housing which tend to reduce rebreathing of others' exhaled air. At 
least today tuberculosis is a population-density disease. 

Recognition of empyema's characteristic rib periostitis lesions as 
described by Kelley may double the frequency of identifiable tuber- 
culous lesions in skeletal populations, although the frequency of 
nontuberculous empyema secondary to pyogenic pneumonia in an- 
tiquity is unknown — a problem resolvable through the study of 
mummies with soft tissue preservation. 



Zagreb Paleopalhology Symp. I98fl 



Porotic hyperostosis: Changing interpretations 

Patty Stuart-Macadam 



Porotic hyperostosis is a paleopathologic condition tiiat has 
intrigued researchers forever 100 years. This time period has 
seen a development of thought concerning both etiology and 
interpretation of the biological significance of the lesions. In 
the past a profusion of terminology existed, but today the 
term porotic hyperostosis (after Angel 1966) is commonly 
used to describe characteristic bone lesions seen in human 
skeletal material. These lesions are usually symmetrical in 
distribution and occur mainly on the orbits (also known as 
cribra orbitalia) and the skull vault, particularly the frontal, 
parietal and occipital bones. The normally smooth, dense 
outer compact bone is replaced by small holes of varying size 
and density. In addition, the middle layer of bone, ordiploe, 
is often increased in thickness. A review of past and current 
ideas on porotic hyperostosis illustrates how science pro- 
gresses by building upon the work of earlier researchers and 
by the development of new interpretations of data as the 
result of changing belief structures or paradigms. 

Early researchers focused on descriptions of the lesions 
and identification of the etiology. Although Welcker ( 1888) 
is credited with the first good description of porotic hyper- 
ostosis, Owen in 1859 may have been the first researcher to 
comment on the lesions observed in skeletal material. In his 
examinationof a collection of early 19th century crania from 
East Asia, Owen came across some striking cases of porotic 
hyperostosis. He noticed great thickening of the cranial vault 
and commented that one skull in particular "is chiefly re- 
markable as exemplifying the rare disease of hypertrophous 
thickening of the parietal bones." Ideas about etiology prolif- 
erated, with suggestions such as pressure from cradle boards 
(Williams 1929), stress of carrying water jugs on the head 
(Wood-Jones 1910), toxic disorders (Hrdlicka 1914), genetic 
trait (Adachi 1904), or nutritional deficiencies (Williams 
1929). 

In 1929 two researchers independently suggested that ane- 
mia may be the causative factor (Moore 1929; Williams 
1929). They based their opinion on the striking similarity 
between radiographs of skulls with porotic hyperostosis and 
those from clinical cases of various hemolytic anemias. In 
both cases, bone changes include an increase in the diploe, 
loss of outer compact bone integrity, and a "hair-on-end" 
appearance of trabeculae. Initially a genetic anemia was im- 
plicated but iron deficiency anemia became a possibility 
36 



when it was realized that it too could produce the characteris- 
tic skull changes. 

Angel ( 1964. 1966, 1967) popularized the idea that a genet- 
ic anemia, particularly thalassemia, could be responsible for 
lesions of porotic hyperostosis in earlier skeletal material . He 
was one of the first researchers to develop a population ap- 
proach to this issue and to have an evolutionary perspective. 
Angel's work on Greek skeletal material suggested to him 
that thalassemia may have occurred as an adaptation to some 
disease such as malaria or amoebiasis. Mo.seley ( 1961 ) was 
the first researcher to suggest that iron deficiency anemia 
may also be a factor in porotic hyperostosis. Hengen, in 
1971 , put forward the hypothesis that iron deficiency anemia 
was the exclusive cause of cribra orbitalia. He had a broad 
perspective and saw the population in terms of its interaction 
with the environment. He considered that parasitic infesta- 
tion and/or an iron deficient diet, consequent on local condi- 
tions, were responsible for porotic hyperostosis. He said; 
"Changes of the hygienic conditions and of the incidence of 
iron deficiency anemias in former times depended without 
doubt largely on deviations of the climate, differences of the 
habits of daily life, procuring and preparation of fotnl, types 
of housing, keeping of domestic animals, disposal of excre- 
ment and so on." 

Later researchers continued to use a population approach 
and to explore the complex interaction of factors behind the 
occurrence of anemia. Carlson et al. (1974) speculated that 
poor diet, parasitic infection, and weanling diarrhea con- 
tributed to the development of iron deficiency anemia in 
Nubian populations. Lallo et al. (1977) suggested a synergis- 
tic relationship between microbial infection, malabsorption 
due to weanling diarrhea, and the nutrient depletion that 
occurs with rapid growth. Mensforth et al. (1978) also 
stressed the multifactorial nature of the problem and illus- 
trated that infectious diseases, represented by periosteal reac- 
tions, can also play a role in the story. 

By the 1970s porotic hyperostosis was considered to be a 
good stress marker for assessing the health and nutritional 
.status of past human skeletal populations. Skeletal popula- 
tions with porotic hyperostosis were considered to be "less 
successful" in adapting to their environment than those with- 
out lesions. The general feeling was that females had a great- 
er incidence of porotic hyperostosis than males, and that this 

'/M^reb Palt'oputholojiy Symp. IVHH 



Porotic hyperostosis: Changing interpretations • 37 



corresponded to modem incidences of iron deficiency ane- 
mia. It was also believed that juveniles had a much higher 
incidence of porotic hyperostosis, hence iron deficiency ane- 
mia, than adults. Some researchers began to equate the pres- 
ence of fKirolic hyperostosis with iron deficient diets. 

By the 1980s some of the assumptions behind these inter- 
pretations began to be challenged. Researchers showed that 
even groups who consumed diets rich in iron suffered from 
porotic hyperostosis (Walker 1986). The belief that porotic 
hyperostosis was more common in females was shown to be 
not true. Statistical analysis of a number of studies revealed 
that in almost every case there was no significant difference 
between males and females in incidence of porotic hyper- 
ostosis (Stuart-Macadam 1982); if porotic hyperostosis was 
due to iron deficiency anemia, then why were there not sig- 
nificant differences between males and females similar to 
those that have been observed in clinical and population stud- 
ies for as long as iron deficiency anemia has been docu- 
mented? 

Consideration of bone marrow physiology and data on iron 
deficiency anemia from clinical studies suggests that lesions 
of porotic hyperostosis in adults are not representative of an 
episode of anemia that was current or had occurred within a 
relatively short period prior to death (Stuart-Macadam 1985). 
In fact, porotic hyperostosis seen in adults is probably indica- 
tive of a childhood episode of anemia, with the resultant bone 
lesions showing incomplete remodeling. This would explain 
the discrepancy between modem demographic patterns of 
iron deficiency anemia and the pattern of porotic hyper- 
ostosis in earlier human populations. In adults, marrow 
hyperplasia can occur without putting undue stress on the 
available marrow space and producing bony response (Stu;ul- 
Macadam 1985). There is no evidence from clinical studies 
to suggest that bone changes as a result of marrow hyper- 
plasia can occur in an adult who has only recently acquired 
iron deficiency anemia. In young children, however, the fac- 
tors of great bone malleability and marrow space already 
filled to capacity with red marrow are likely to lead to bone 
change in response to increased demands for red blood cells. 

These ideas have implications for the interpretation of por- 
otic hyperostosis seen in past human skeletal populations. If 
iron deficiency anemia acquired in adulthood does not lead to 
bone change then the higher incidence of porotic hyper- 
ostosis (therefore anemia) observed in juveniles does not 
necessarily reflect reality. Juveniles may or may not have had 
a higher incidence of anemia than adults; it is simply not 
possible to assess the impact that anemia may have had on 
adults. If porotic hyperostosis in adults does reflect a child- 
hood episode of anemia, then the search for causative factors 
should concentrate on the juvenile sector of the population. It 
is also important to be aware that the total number of individ- 
uals afl'ectcd by anemia will always be undcrrcprcscnied in a 
skeletal population. At most, 50-75% of clinical patients 
with anemias that are associated with bone change show 
changes which can be .seen radiographically (Stuart-Macadam 

Zagrrb Paleopalhology Symp. I98S 



1985). As a result of all these factors it may be impossible to 
assess the true pattern of anemia in any past human skeletal 
population. 

Stuart-Macadam (1982,1987b) expanded on the ideas of 
some of the earlier researchers by undertaking a detailed 
comparison of radiographs from clinical cases of anemia 
with radiographs of skulls with porotic hyperostosis. On the 
basis of seven criteria, it was felt that the data strongly sup- 
ported the hypothesis that porotic hyperostosis was indeed 
the result of an anemia. In addition, three lines of evidence 
supported the hypothesis that porotic hyperostosis is more 
likely due to iron deficiency anemia than a genetic anemia: 

1 . Calculations based on the highest gene frequencies for 
genetic anemias seen today show that the probability of find- 
ing individuals from archeologlcal collections with skeletal 
changes due to genetic anemia is quite low (Stuart-Macadam 
1982). 

2. There are high levels of porotic hyperostosis in skeletal 
groups from northern Europe and North America, areas 
where genetic anemias did not exist in the past. 

3. The severe bone changes associated with genetic ane- 
mias, particularly postcranially, have not been substantiated 
for any individuals from archeological collections. 

Recently, Stuart-Macadam ( 1987a) has questioned the bi- 
ological significance of porotic hyperostosis. Fomierly its 
presence in a skeletal population has been seen as an inability 
to adapt, a negative response on the part of the body. It has 
been assumed that skeletal groups with high levels of porotic 
hyperostosis were less "successful" than groups with lower 
levels of porotic hyperostosis. It may be that it is actually a 
positive response and a sign of a healthy defense system. 
This view has arisen out of changing perspectives of the 
immune system, and iron deficiency in particular. A large 
body of data supports the concept that iron deficiency may 
not always be detrimental, but may actually strengthen the 
body's defenses against infection (Strauss 1978). Lowered 
iron levels may be a natural protective respon.se which dis- 
courages bacteria and other pathogens. Microbes are depen- 
dent upon assimilation of iron and actually synthesize sub- 
stances which have the ability to bind iron. In this situation 
hypoferremia should be advantageous to the host and disad- 
vantageous to the microbial invader. In vitro, in vivo, and 
population studies show that this is very often the case 
(Lukens 1975; Strauss 1978; Wadsworth 1975). 

Normally there is a balance between the role of iron in the 
defense system and the body's requirements for iron. Iron 
metabolism is basically a closed system, since losses are 
normally very low and iron obtained from destruction of old 
blood cells by the reticuloendothelial system is recycled 
within the body. In times of extra iron requirements the intes- 
tine absorbs a greater percentage of the iron available in the 
diet. It is possible that only continual and repealed exposure 
to a large number of pathogens can destroy this balance in a 
normal individual and ultimately lead to iron deficiency ane- 
mia. In this view it is possible that the lesions of porotic 



38 • Patty Stuart-Macadam 



hyperostosis reflect a positive response on the part ot the 
body to the total pathogen load of the environment (Stuart- 
Macadam 1987a). In areas where the load of pathogens (vir- 
uses, bacteria, fungi, parasites) is high, it would be expected 
that greater numbers of the population would cross the 
threshold between an iron deficiency as an adaptive re- 
sponse, and an iron deficiency anemia. 

An examination of the demographic picture of porotic hy- 
perostosis in earlier populations should provide clues to the 
biological significance of the condition. Porotic hyperostosis 
begins to appear in Neolithic times (Stuart-Macadam 1987a), 
it is more prevalent the closer the group is to the equator 
(Hengen 1971), it occurs with greater frequency on lowland 
sites than highland (Hrdlicka 1914; El-Najjar et al. 1976; 
Ubelaker 1984), it has decreased in modem times in northern 
Europe (Hengen 1971), and it occurs in nonhuman primates 
(Nathan and Haas 1966). What is the significance of this? 
Building on the ideas of previous researchers who have sug- 
gested that porotic hyperostosis is the result of the interaction 
of customs, diet, hygiene, parasites, and infectious diseases, 
the concept of porotic hyperostosis as a response to high 
pathogen loads could explain why individuals from archeo- 
logical sites who appear to have diets rich in iron and protein 
still have high levels of porotic hyperostosis. It could explain 
the fact that porotic hyperostosis is more common in areas 
such as lowland sites and tropical areas: these are areas of 
higher pathogen loads. It could also explain why porotic 
hyperostosis starts becoming common in the Neolithic, not 
because of agriculture or changes in diet per se, but because 
of greater population density which means greater exposure 
to pathogens. 

In the past, signs of chronic disease in skeletal material 
have been interpreted as an inability to adapt to the environ- 
ment. However, it is becoming more widely accepted that 
disease is the defense system's fight for health; in this view 
evidence for chronic disease on the skeleton is seen as a 
positive adaptation, a fight for health against the pathogen. 
As Powell (1986) has said, "since bone lesions typically 
occur relatively late in the progress of the disease after con- 
siderable soft tissue involvement has commenced, their very 
presence is indicative of long-term immune response to in- 
fection." By a .shift in paradigm, individuals with chronic 
bone lesions can be seen to have been more successful in 
adapting to their environment than individuals who did not 
live long enough to produce bony response to a pathogen. If 
this is true, then skeletal populations that show signs of 
chronic bone lesions may not be less "successful" than popu- 
lations that do not show signs of chronic bones lesions. Of 
course, ultimately, fertility and longevity are the true indica- 
tors of successful adaptation. 

Another shift in perception in recent years has been an 
understanding of the complexities of the interaction between 
the host, pathogen, and environment. Scrimshaw (1964) 



wrote a classic paper in which he emphasized that the disease 
agent is only one of a triad with host factors and environmen- 
tal factors. He said that simply identifying the agent is not 
sufficient to describe its cause. It must be seen as part of a 
complex interrelationship which is dynamic, and unique to 
every individual. These views are reflected in the more re- 
cent work on porotic hyperostosis, as researchers carefully 
examine as many variables as possible in the complex inter- 
action between a population and its environment. 

This paper has presented a review of the research on poro- 
tic hyperostosis and the development of thought that has 
occurred over the past century regarding etiology and inter- 
pretation. Most earlier work would fit into Armelagos et al.'s 
(1982) descriptive-historical model of research. This refers 
to research which focuses mainly on data description and 
discussion of individual cases of paleopathology. In recent 
years, there has been a shift to a population approach that 
stresses functional interpretation of data. At the same time, 
concepts of health and disease have been changing, along 
with perceptions of the body and its immune system. These 
trends have had a profound effect on research into porotic 
hyperostosis and have stimulated new ideas and interpreta- 
tions of data. 



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phol(>i>i(' unii Anthropologie . l.'il'i. 
Angel, J.L. 1964. Osteoporosis; Thalassemia? AmenVn/iy^x/rna/o/ 

Physical Anthropology. 4 1 : 103- 1 06. 
1966. Porotic Hyperostosis, Anemias, Malarias and the 

Marshes in Prehistoric Eastern Mediterranean. Science, 

153:760-762. 
1967. Porotic Hyperostosis or Osteoporosis Symmetrica. 



In D. Brothwcl! and A.T. Sandison. eds.. Diseases in Antiquity, 
378-389. Springfield, 111.: Charles C Thomas. 

Armelagos, G.J., D.S. Carlson, and D.P. van Gervcn. 1982. The 
Theoretical Foundation and Development of Skeletal Biology. In 
F. Spencer, ed.. A History of American Physical Anthropology 
1930-1980. 305-328. New York; Academic Press. 

Carlson, D., G.J. Armelagos, and D. van Gervcn. 1974. Factors 
Influencing the Etiology of Cribra Orbitalia in Prehistoric Nubia. 
Journal of Human Evolution, 3:405-410. 

El-Najjar, M. . D.J. Ryan. C.G. Turner II. and B. Lozoflf. 1976. The 
Etiology of Porotic Hyperostosis Among the Prehistoric and His- 
toric Ana.sazi Indians of the Southwcstem U.S. American Jour- 
nal of Physical Anthropology. 44:477-488. 

Hengen. OP. 1971. Cribra Orbitalia: Pathogenesis and Probably 
Etiology. Homo. 22:57-75. 

Hrdlicka. A. 1914. Anthropological Work in Peru in 1913, with 
Notes on Pathology of Ancient Peruvians. Smithsonian Mis- 
cellaneous Collections, 61:1-69. 

Lallo. J.. G.J. Annelagos, and R.P. Mcnsforth. 1977. The Role of 
Diet. Disease and Physiology in the Origin of Porotic Hyper- 
ostosis. Human Biology. 49:471-483. 



Zafireb Paleopathology Symp. 19HH 



l\)rotic hyperostosis: Changing inteqDretations • 39 



Lukens. J. 1975. Iron Deficiency and Infection. Amerkon JoiinutI 
of Diseases of CliiUtren , 1 29; 1 60- 1 62 . 

Mensforth. R.. C. Lovejoy, J. Lallo, and G.J. Armclagos. 1978. 
The Role of Constitutional Factors. Diet, and Infectious Disease 
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Moscley, J.E. 1961. Skull Changes in Chronic Iron Deficiency 
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Moore. S. 1929. Bone Changes in Sickle Cell Anemia with Note on 
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Journal of Missouri Stale Medical Association, 26:561-564. 

Nathan. H. andN. Haas. 1966. The Presence of CribraOrbitalia in 
Apes and Monkeys. American Journal of Physical Anlhnipoloiiy. 
24:351-360. 

Owen. R. 1859. Report on a Series of Skulls of Various Tribes of 
Mankind Inhabiting Nepal. Collected and Presented to the Muse- 
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Albuquerque. New Mexico. 

Scrimshaw, N. 1964. Perspectives in Nutrition. American Journal 
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Strauss. R. 1978. Iron Deficiency. Infection, and Immune Function: 
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31:660-666. 

Stuart-Macadam, P.L. 1982. A Correlative Study of a Pal- 
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U.K. 

1985. Porotic Hyperostosis: Representative of a Childhood 

Condition . American Journal of Physical Anthropology. 66:39 1 - 
398. 

1987a. Nutrition and Anaemia in Past Human Populations. 



Chacmoal. Alberta, Canada: University of Calgary. 

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Summary of audience discussion: Porotic hyperostosis presents 
problems of both diagnosis and etiology. Minor osteoporotic pitting 
or outer table erosion above the temporal lines and on frontal 
squama as well as above the occipital crest without frank thickening 
should probably be given a descriptive label which does not bear the 
etiological implications presumed for porotic hyperostosis. Site 
specificity can also be a problem. While the material reviewed in 
this presentation demonstrated involvement of both cranial porotic 
hyperostosis and orbital cribra orbitalia in 90% of the individuals 
studied, the range of such associations varies from to 100% in 
different groups. It should be remembered that porotic hyperostosis 
is an indicator of childhood, not adult, anemia, and that iron defi- 
ciency anemia may be the consequence of blood loss or pathological 
absorptive conditions even in individuals consuming diets of nor- 
mally adequate iron content. Some orbital porous lesions appear to 
be of infectious origin; in sickle-cell anemia the orbital cases occur 
at 4-5 years of age. 



Zagreb Paleopathology Symp. 1988 



Diagnosis of occupationally related 
paleopathology: Can it be done? 

Ann Stirland 



1 he occupations followed by people in the past and the 
activities in which they most widely indulged have probably 
not changed greatly until recently. The development of mod- 
em technology has brought changes in occupations, tool 
types and usages that may in time produce characteristic 
skeletal variations. There are already reports in the clinical 
literature relating such changes to occupation (Mintz and 
Fraga 1973). In the past, activity-related pathology may have 
been expressed as stress fractures of the tibia in hunter- 
gatherer groups which "ran down" their large prey. No matter 
how good the preservation and recovery of artifacts from an 
archeological site, however, the interpretation of their use 
and the activities involved relies heavily on assumptions 
based on ethnographic and historical parallels. Such interpre- 
tation is speculative. 

It is a truism that an archeological site usually has no 
documentary records. The occupations and activities of its 
population are, therefore, unknown except from their ar- 
tifacts. Paleopathological diagnosis brings its own problems. 
Human bone has only two responses to any insult: either 
normal bone is lost or new bone is added. Such limited re- 
sponses lead to difficulties in equating specific pathological 
lesions with particular occupations. Hven in a modern clini- 
cal context diagnosis is an inexact science, and many of the 
relationships between occupation and pathology are still not 
clearly understood. Much occupational pathology will be 
confined to soft tissue and will leave no record on the skel- 
eton. There is also the problem of distinguishing lesions 
which are attributable to a direct traumatic event, age de- 
generation, or developmental defects from those specifically 
related to occupation. 

Paleopathologists have only recently attempted to relate 
some pathology to occupation, and they arc constantly made 
aware of the problems and limitations of such interpretation 
of the material. There are, however, some positive aspects. 
Unlike the clinician, the paleopathologist is working with the 
whole dry skeleton. Changes in bone are seen in their very 
early stages and conditions which may be clinically symp- 
tomless can be detected. 
40 



Occupationally related paleopathology is, by definition, 
nonrandom and habitual. If, despite the problems, some oc- 
cupations can be diagnosed then this will provide an impor- 
tant tool in archeological reconstruction. The ability to iden- 
tify some skills, trades or professions can lead to the 
extrapolation of this evidence into other sites and periods, 
making a further valuable contribution to archeology. 

Skeletal studies 

The only comprehensive skeletal study of activity-induced 
pathology so far produced is that by Merbs ( 1983). Although 
the Sadlermiut series analyzed was not particularly large, 
consisting of 41 male and 50 female adult skeletons, the 
group was thought to meet many of the necessary criteria for 
such a study (Merbs 1983:4,5). These include a limited num- 
ber of specialized, but known, activities, good skeletal pres- 
ervation and recovery, a relatively narrow time span, and 
both cultural and genetic isolation. The paleopathological 
lesions in the group were evaluated in six categories: os- 
teoarthritis, osteophytosis, vertebral compression, other de- 
generative features of the vertebral column (porosity of the 
articular body surfaces, Schmorl's nodes and laminal spurs), 
spondylolysis, and anterior tooth loss. The largest category 
was that of osteoarthritis. Merbs analyzed Sadlermiut ac- 
tivity patterns and discussed their possible stresses on areas 
of the skeleton (1983: 147-156). He correlated the patterns of 
activity and pathology. In his conclusions. Merbs argued that 
the osteophytosis of the vertebral columns is a normal de- 
generative condition and a consequence of bipedalism. A 
number of the other pathological lesions, however, were cor- 
related with particular activities, known or reconstructed. 
Both sex and side differences were shown to be important. 
Of particular interest were some elements of specific ac- 
tivities which had not been anticipated during Merbs's recon- 
struction of Sadlermiut behavior patterns. These elements 
were suggested, however, by particular patterns of pathology 
(Merbs 1983:184). This unexpected result provides an op- 
timistic conclusion to the study and suggests further potential 
for such reconstruction. 

Zagreb Paleopalholony Symp. t*^HH 



Diagnosis of occupationally related paleopathology • 41 



Another activity-related skeletal study by Dutour (1986) 
postulates enthesopathies as indicators of activities in two 
Neolithic populations. There are. however, problems with 
this work. Both groups studied were small, consisting of only 
41 skeletons in total. Of these 21 were unsexable. Dutour 
does not differentiate between enthesis, attachments of mus- 
cles, and syndesmoses, attachments of ligaments (1986:224). 
He calls all his observed lesions enthesopathies although 
some are in areas of ligamentous and not tendinous insertion. 
This is particularly important since it concerns his recon- 
struction of a possible archer (1986:222). Here, the en- 
thesopathies of the right radius have been combined with 
degenerative changes to the synovial joints at both elbows 
and with developments of muscle insertions on both humeri. 
All these changes are not enthesopathies and the synovial 
joint changes may be age related. Dutour does not appear to 
take such age-related degeneration into account when dis- 
cussing the etiology of the lesions. It is clear, however, from 
the literature that enthesopathies are degenerative in nature 
and are "common in older individuals" (Resnick and 
Niwayama 1981:1297). Apart from using such categories as 
"juvenile," "mature adult" and, in one case, "aged male," no 
indication of age ranges is given. In attempting to diagno.se 
activity-related changes, the relative ages of the individuals 
concerned are of importance. When enthesopathies which 
are not metabolic or inllammatory in origin are thought to be 
degenerative in nature, then age becomes a key question. 
However, as the changes concerned may be accelerated by 
trauma or chronic stress ( Resnick and Niwayama 1 98 1 : 1 3(X)) 
and, therefore, activity, the picture may be more complex 
than would appear from Dutour's paper. The problem is once 
again one of specificity. 

In a recent paper. Waldron ( 1 987) discussed a site in which 
there is some documentary evidence of occupation from buri- 
al registers. Although this work is only in its early stages it is 
of great interest. Of the 336 adults so far examined from 
Christ Church. Spitalfields, 37.2% have osteoarthritis. This 
occurs most commonly in the spine, but the shoulders and 
hands are also involved. The hands are of particular interest 
since Spitalfields was a very important silk-weaving center, 
and the disease here may be related to occupational factors. 

One of the problems associated with the diagnosis of occu- 
pationally related pathology is concerned with current termi- 
nology. An example is the use of the term "degenerative 
change." Some specialists use it to denote age-related 
changes, while others are concerned with the deterioration of 
joint surfaces resulting in destruction or proliferation of 
bone. Ortner( 1968: 141) studied two large skeletal groups in 
order to classify degenerative change in the humeral elbow. 
This study uses the term in the latter sense and stresses the 
importance of handedness, sex, and cultural practices in de- 
generative change. Ortner (1968:144) also emphasizes the 
significance of age in the degree of degeneration in a joint, 
and discusses mechanical stress, anatomy, and heredity as 
other determining factors. 

Zagreb Paleopaihotogy Symp. I98H 



These skeletal studies, while subject to inherent problems, 
do attempt to describe possible occupationally related 
changes and to categorize some of them. 

Clinical studies 

The traditional clinical postulate has been that in os- 
teoarthritis, particularly of the spine, an occupational com- 
ponent is present. In the public as well as the specialist mind, 
pathology of joints has often been associated with usage. 
This is reflected in the popular terminology often associated 
with overuse syndromes, such as "tennis elbow." However, 
the modern clinical view of the role of activity in the develop- 
ment of osteoarthritis is, to say the least, ambivalent. The 
traditional view is represented by studies such as those on 
coal miners (Lawrence 1955), dockyard workers (Anderson 
and Duthie 1963), and by some theoretical works (Radin et 
al. 1972). Other work, however, such as that by Hadler, 
presents a different view. In his first study, Hadler stresses the 
anecdotal nature of much of the clinical correlation between 
activity and some musculoskeletal disease, and points out 
that the amount of true clinical information is somewhat 
inadequate. He suggests alternative strategies for clinical 
studies to gather the necessary information (1977:1023). 
These studies are implemented in later work on patterns of 
repetitive, stereotyped usage in the hands of female textile 
workers ( Hadler etal. 1978; Hadler 1980). It is clear that this 
later work considers degenerative joint disease to be a highly 
prevalent process of aging throughout the entire population, 
and not confined to specific groups; repetitive, stereotyped 
tasks and side are both involved in the degenerative syn- 
drome. 

Anderson found in a study of manual workers that, after 
allowing for age, heavier work significantly increased the 
likelihood of rheumatic complaints in general and degenera- 
tive disc disease in particular, but not of osteoarthritis of the 
other joints (1974:523). He also concluded that such disea.ses 
are likely to develop earlier among heavy manual workers 
(1974:524). In a later study. Anderson identified the impor- 
tance of side, age, biochemical changes and their genetic 
bases, and chronic irritation in the development of os- 
teoarthritis (1984:431 ). He argued "that the development of 
degenerative changes can be triggered in those at risk" either 
by a severe impact which damages the cartilaginous joint 
lining, or by chronic stress over a long period producing 
fatigue in a joint. Both posture and mobility were seen to be 
important in these changes. 

Lockshin et al. (1969) surveyed arthritic complaints in 
more than 1 1(K) men from three mining communities in West 
Virginia. The main differences between the groups were that 
in the 60-69 age group. 68.9% of miners had osteoarthritis of 
the cervical spine grades 2-4. conipared with 56.9% of non- 
miners (1969:24). Unlike similar British work (Lawrence 
1955). these authors found no difference in the prevalence of 
disc degeneration m the lumbar spine between miners and 



42 • Ann Stirland 



nonminers. This was attributed either to an unexplained 
higher prevalence in nonminers or to a difference in working 
environments in the two countries. Similarly, in a Finnish 
study of lumberjacks, no correlation could be found between 
the period of heavy work and disc degeneration when the age 
factor was removed (Sairanen et al. 1981 ). The authors con- 
cluded that various factors seem to be involved in the etiol- 
ogy of disc degeneration, as well as age and mechanical 
stress. Heredity and autoimmunization may be involved in 
these changes, making it difficult to assess the role of heavy 
work. Osteoarthritis was thought to have a multifactorial 
etiology (Sairanen et al. 198 1 :27), and ergonomically correct 
work was found to be very important in its lack of develop- 
ment. Lindberg and Danielsson (1984) were also unable in 
their study to demonstrate any relationship between occupa- 
tion and coxarthrosis in shipyard workers involved in heavy 
labor. 

Some of the preceding papers, and much of the fundamen- 
tal work in this field, are excellently reviewed by Hagberg 
(1984). In this review, the controversial nature of the etiology 
of the degenerative arthropathies, the enthesopathies, and 
their relationship to occupational stress are clearly discussed 
and evaluated in the context of disorders of the neck and 
shoulder (1984:270-275). This work emphasizes what must 
by now be clear. The role of occupational stress as a factor in 
osteoarthritis is far from unequivocal. This is partly a func- 
tion of the classification of work by occupation (e.g., 
"miners"), rather than by actual task or evaluation of stress, 
or by loading on skeletal areas. The necessary information is 
also .spread over many different specialized medical fields 
and its interpretation can suffer from the constraints of differ- 
ing opinions. 

The changes due to osteoarthritis or to degenerative joint 
disease are not the only ones that may be related to activity in 
the skeleton. Lesions may be present whose pathogenesis is 
clear but in a different context. An example is the group of 
enthesopathies. In this case, the lesion may be degenerative 
(related to age) in one context, but occur in a young, robust 
individual in another. If direct trauma or disease can be elimi- 
nated as a causative agent, then another explanation has to be 
found for the lesions. 

Other morphological variants used as occupational stress 
markers are supinator crests and fossae of ulnae (Kennedy 
1983). The hypertrophy of the crests, deepening of the fos- 
sae, and "ridging" of the insertion of the anconeus muscle 
were found in prehistoric samples in males "known" to have 
used missile weapons such as spears (Kennedy 1983:872). 
Similar changes also occurred in modem populations, in both 
sexes, who were habitually engaged in occupational or ath- 
letic activities involving similar patterns of arm movement. 
Changes at the elbow which can be directly related to occupa- 
tion are also apparent in baseball players (Bennett 1959). 
Damage to hyaline cartilage, olecranon fractures, and spur 
formation occur as a result of persistent, chronic strain. 



Chronic bursitis and fraying of both supraspinatus and biceps 
tendons are recorded as a result of strain and overuse. 

The previous examples resulted in the formation of pro- 
liferative new bone at various sites in the upper girdle. An- 
other syndrome associated with activity-related stress is os- 
teolysis of the distal clavicle (Kaplan and Resnick 1986). 
This pathology is known to occur clinically after acute trau- 
matic injury to the shoulder. In the cases cited here, it was 
also found to occur secondary to repeated microtrauma of the 
acromioclavicular joint. The main case is of a 39-year-old 
male who worked in a bakery, lifting heavy pans of rolls in 
and out of ovens all day. There had been no single traumatic 
event. Similar, atraumatic pathological changes have been 
noted in other occupations involving loading, such as air- 
hammer operator or oxygen tank delivery man, and also in 
athletes, such as weight-lifters and handball players. 

The clinical existence and reporting of pathological 
changes other than those associated with osteoarthritis in the 
human skeleton is encouraging. Although the arthropathies 
are the most common pathological changes observed in ar- 
cheological skeletal material, other lesions do occur. While 
some of these are truly pathological and are a consequence of 
a disease process, others quite clearly are not. It is common 
to attribute the term "pathological" to anything that is abnor- 
mal. Such abnormalities include some of the changes already 
discussed, such as the enthesopathies, and those due to over- 
use or activity. Can such abnormal changes be used in the 
diagnosis of occupationally related paleopathology? 

The Mary Rose 

One of the more serious problems encountered in the analysis 
and interpretation of archeological human skeletal material is 
the lack of spatial and temporal controls for a particular site. 
This problem is part of the wider one already referred to, 
namely, the general lack of any documentary evidence. Very 
rarely is a site excavated in which these problems are mini- 
mized. Such a site is Henry VIII's flagship, the Mary Rose. 
The Mary Rose was sunk on the morning of 19 July 1545 
after having emerged from her home port of Portsmouth, 
England, at the head of the English fleet. The object was to 
engage the French fleet moored nearby. The ship apparently 
executed a bad turn to starboard and, in attempting to raise 
sail, took in water through open gun ports, heeled over and 
sank rapidly, settling heavily into the soft seabed silts. Of the 
crew of 415 men all but about 35 drowned, including the 
captain, the master, and the vice admiral. Most were trapped 
under the stout antiboarding netting which covered the 
decks. The ship came to rest on her starboard side and silted 
up within a matter of months. The exposed port side was 
eroded by the sea until it collapsed, leaving intact the com- 
plete starboard half. The wreck was then sealed in the 16th 
century by a hard, shelly seabed and remained hidden, apart 
from the occasional severe winter storm, until it was discov- 
ered in 1968. The rapid silting and sealing provided a perfect 

Zagreb Paleopathology Symp. 1 988 



Diagnosis of occupationally related paieopatiiology • 43 



anaerobic environment in which much organic material, in- 
cluding the human skeletal remains, was exceptionally well 
preserved. The position and condition of the wreck led to a 
commingling of the skeletal material both within individual 
deck sectors and probably, in some cases, from one deck to 
another. An account of the finding, excavation, and raising of 
the Mary Rose may be found in Rule ( 1982. 1983). 

Henry VIll had a list of his ships compiled by Anthony 
Anthony and this was completed in 1546 (Rule 1982:26-28). 
This list contains the only contemporary picture of the Mary 
Rose and includes crew numbers and their occupations (Rule 
1982:27). It also includes lists of all the ordinance and equip- 
ment for the war. In the case of the men of the Mary Rose. 
therefore, the actual date and cause of death is known as is 
their equipment and occupations. This sample, like Merbs's 
Sadlemiiut, meets many of the criteria for the study of ac- 
tivity- or occupationally related pathology. There is, how- 
ever, one problem that Merbs did not have; it is a very com- 
mingled group. Because of the unique nature of this sample, 
its importance and the possibility of undertaking such a 
study, it was decided to try to re-sort the bones where possible 
into individuals. This was undertaken initially for the pur- 
poses of the bone report submitted in 1985. Because of pres- 
sure of time (money), the re-sorting was accomplished only 
within the deck sectors and not attempted from one deck to 
another. A skull and mandible count produced a minimum 
number of 179 individuals; the re-sorting generated 9 1 fairly 
complete skeletons, some more complete than others. 

Experience suggests that an archeological sample of hu- 
man remains generally displays a fairly common collection 
of pathological lesions. Many of these lesions are expressed 
in joint changes as arthropathies. Apart from the arthropa- 
thies, healed fractures are commonly seen as in nonspecific 
periostitis and. in the New World at least, porotic hyper- 
ostosis and cribra orbitalia. In some specific groups and time 
f)eriods, evidence for tuberculosis and for leprosy can be 
identified. Other lesions occur generally much less com- 
monly in such material, although they may have a more 
widespread clinical expression. They include such examples 
as osteochondritis dissecans, Osgood-Schlatter's and Scheuer- 
mann's diseases. There are other conditions, such as os acro- 
miale, which are very rare and have a low expression in any 
group, and there are morphological changes, such as the 
enthesopathies, which have a much higher frequency in some 
groups than in others. In the sample from the Mary Rose, we 
are concerned with the last three groups rather than the more 
common ones. 

Predictably for a fighting ship, most of the men of the 
Mary Rose were young and some of them were very young. 
There was a predominance of individuals ranging from 1 5 to 
25 years with a smaller group in their late twenties/early 
thirties. There was also a very small number of both very 
young (10-15) and older (35-45 + ) men. Before discussing 
the patterns of pathology, it must he pointed out that, owing 
to the problems of mixing, pathology in this group has so far 

Zofireb Paleopathology Symp. 1988 



been assessed by bone, rather than by individual. It is ac- 
cepted that, for the arthropathies at least, this situation is 
undesirable (Rogers et al. 1987). and discussion on arthritic 
changes has, therefore, been omitted. 

The area of the skeleton displaying the most pathology is 
the vertebral column. There are nine cases of spondylolysis, 
including one of spondylolisthesis but, apart from these, 
most of the lesions arc in the thoracic segment. The most 
common of these lesions is Schmorl's nodes, and they occur 
in some subpubescent spines where the centra are still very 
billowed and the epiphyseal ring is unfused. Such car- 
tilaginous nodes have a varied etiology (Resnick and 
Niwayama 1981:1404). If they are not degenerative or re- 
lated to various diseases, however, they are often a conse- 
quence of trauma. One of the diseases in which Schmorl's 
nodes occurs is Scheuermann's disease. This condition also 
has a high frequency in the sample, in the thoracic spine. As 
it is a juvenile condition, it occurs in very young spines, 
although the evidence is al.so retained in older individuals. 
Much of the modem work on Scheuermann's disease sug- 
gests that it is probably a manifestation of the node formation 
and a result of the failure of the cartilaginous end plate under 
stress which can be traumatically induced. In the sample 
there are also marked changes in the shape of the centra in the 
thoracic spine, producing an expansion, often in an anterior 
direction. Thoracic scoliosis is also apparent, as is twisting of 
some apophyseal joints, particularly at the lower end where 
there is also some gross enlargement of such joints. This is 
particularly true in the case of three of the matched, fairly 
complete skeletons. They are all young, in their early to mid- 
twenties, and they all exhibit a great deal of stress to the 
thoracic and lumbar areas. One in particular has extraordi- 
nary vertebrae. All are large and robust with huge apophyseal 
joints, particularly TlO-12. Both Til and T12 look like 
lumbar vertebrae, with characteristic curved articulations 
(Figure 1), and the sacrum and innominates are also very 
large with deep articulations. All three of these skeletons 
were found on the Main Gun deck in close association with 
one of the very heavy bronze cannon. These cannons 
weighed up to two tons and were operated entirely by hand by 
a gun crew, being hauled in and out of the gun port on a 
wooden carriage. The hall shot used was also very heavy and 
had to be fetched in baskets from the Orlop deck below. 

Two other conditions which are a consequence of trauma 
resulting in damage to an epiphysis are osteochondritis dis.se- 
cans and Osgood-Schlatter's disease. Both are more frequent 
clinically in the young and both afTect boys more than girls. 
Neither are seen commonly in archeological samples. In the 
sample from the Mary Ro.se. there are high frequencies of 
both. The most common site for osteochondritis dissecans is 
the first metatarso-phalangeal joint. There are 23 affected 
bones: 1 6 examples occur on the distal humeral condyles and 
7 on the distal femoral condyles, some bilaterally (Figure 2). 
There are six cases, two left and four right, of unusual pits 
occurring in femoral heads, superior to the fovea (Figure 3). 



44 • Ann Stirland 





Figure 2. Bilateral osteochondritis dissecans. 



Figure 1 . Gross enlargement of lower tho- 
racic apophyseal joints (arrows). (All speci- 
mens illustrated in this paper are courtesy of 
the Mary Rose Trust.) 




Figure 3. Pits in femoral heads. 



These have also been identified as osteochondritis dissecans 
(I. Watt 1984, pers. comm.), although an alternative diag- 
nosis of avascular necrosis has been suggested (D. Birkett 
1986, pers. comm.). Eleven left and 12 right tibiae exhibit 
Osgood-Schlatter's disease. Some are very young with new- 
ly fused epiphysis and in some cases it is bilateral (Figure 4). 

Os acromiale is a rare anomaly which has already been 
described for this group (Stirland 1987). The data in this 
earlier paper have now been updated and the frequency is 
12.5%. With a normal frequency of from 2% to 6%, the 
values for this sample are high. It is argued that os acromiale 
in this case may be related to long-term use of the very heavy 
longbows by the professional archers on the ship. The per- 
sistent use of this weapon, with its draw weight of about 57 
kg ( 125 lb), from a very early age was responsible for long- 
term shearing stresses on the acromion which inhibited fu- 
sion of the final element. The inflammatory nature of the 
unfused elements suggests the surfaces were subjected to 
such stresses in these cases (Figure 5). 

A defect in the rim of the acetabulum, usually in the pos- 
terior portion, has been called an acetabular flange lesion 
(Knowles 1983). In the absence of other serious pathology of 
the acetabulum or the femoral head its etiology is unclear. It 



has been suggested that it is produced by a "transient, in- 
complete, upward dislocation of the femoral head" (Knowles 
1983:65), which does not affect the femur. Eleven innomi- 
nates, four left and seven right, from this group are affected 
by this lesion (Figure 6). Another suggestion offered is that it 
is a defect in the fusion of the pelvic elements (I. Watt 1986, 
pers. comm.). The appearance of these particular innomi- 
nates, however, where there is pitting of the affected rim, 
suggests a traumatic origin associated with activity but not 
serious enough to be permanently disabling. 

Enthesopathies are widespread in the burials from the 
Mary Rose. These range from development of the linea as- 
pera, gluteal ridge, and hypotrochanteric fossa on the pos- 
terior femur (Figure 7) to lesions at the insertions of pec- 
toralis and teres major on the humerus and of biceps on the 
radius (Figure 8). There are many other examples and all are 
widespread throughout the sample. Enthesopathies also oc- 
cur in the form of spurring, especially of the trochanters, 
calcaneus and , to a lesser extent , the olecranon process of the 
ulna. Some syndesmoses, particularly of the costoclavicular 
ligament, show similar changes (Figure 9), with lesions and 
some bony buildup. The exuberant nature of these changes, 
which far exceed those normally .seen in archeological mate- 
rial, must be explained in terms of processes. 

Zagreb Paleopalholony Symp. 19SH 



Diagnosis of occupationally related paleopathology • 45 






^ 

'•>! 


^^ 


^^ 


■^ 






^^^^^r m ^H ^H ^B ^H ^B 




^ 1 













Figure 4. Bilateral Osgood-Schlatter's disease. 



Figure 6. Acetabular flange lesion of left innominate {ar- 
rows). 



Figure 5. Bilateral os acromiale. 




The rigorous physical demands of their working environ- 
ment must have put heavy stresses on the developing skel- 
etons of these young men. The mariners were working with 
four masts, all of which bore canvas and required servicing. 
The ship had a small keel and very little ballast and was, 
therefore, unstable at the best of times. Men and boys must 
have fallen and slipped while trying to release or furl sails. 
The loading stresses associated with the operation of the guns 
and with the longbows has already been discussed. The 
amount and type of pathology and the degree of bony re- 
modeling of various fibrous insertions in this sample has to 
be explained in terms of their environment. These would 
appear to be changes due to occupation in some members ot 
the crew of the Mary Rose. Some of these are pathological 
and some morphological. The former may be due to work- 
related trauma, while the latter appear to be related to loading 

Zagreb Paleopathology Symp. 1988 



stres.ses. All, therefore, may well be a consequence of occu- 
pation. The relationships between these changes and specific 
occupations is, however, another matter. 



Conclusions 

The concept of relating specific skeletal changes to particular 
activities is a comparatively recent one. As has been shown, 
clinical work is controversial and paleopathology is faced 
with problems associated with the nature of the material and 
the lack of proper controls. Some samples, however, arc able 
to overcome these pri)blcms to a greater or lesser extent and 
these should be utilized to implement further studies. An 
example is the work of Merbs already cited. The sample from 
the Mary Ro.sc wnuld appear to be another. 



46 • Ann Stirland 





Figure 8. Enthesopathies of humerus and radius (arrows). 



Figure 7. Development of linea aspera, gluteal ridge, 
and hypotrochantic fossa (arrows). 




Figure 9. Lesions of clavicular syndesmoses 
(arrows). 



Although such work is difficult, some contribution may be 
made. In an archeological sample, it will never be possible to 
extrapolate from the general to the particular and assign an 
individual's occupation from a group study. In a personal 
sense, I will never be able to say: "This man was an archer." 
What needs to be done, however, is to compare specific 
groups. Such comparison must obviously be as rigorous as 



possible, so that groups from the same time period and/or 
geographical area should be compared. What is needed is 
similarity studies (Waldron 1987, pers. comm.). In this way, 
groups could be compared for similarities and differences. 
When all other factors, such as age, sex, and side, are equal, 
then differences, such as have been described for the Mary 
Rose crew, can be related to a group activity or occupation. 

Zagreb Pateopiilbology Symp. IWH 



Diagnosis of occupational ly related paleopathology • 47 



With regard to the Mary Rose, a research program has been 
undertaken which will implement such group studies. Other 
large medieval groups from southern England will be com- 
pared with that sample and the differences will be evaluated. 
Perhaps then it will be possible to say with more confidence 
that, all else being equal, the sample from the Mary Rose is 
different and these differences are due to the occupations 
followed by the crew. 



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Summary of audience discussion: Discussion quickly made it 
clear that the audience was divided on the question of whether the 
lesions demonstrated as osteochondritis dissecans were of meta- 
bolic, traumatic, or even developmental nature. Several felt they 
had seen similar lesions under circumstances making it reasonable 
to relate them to occupations resulting from prolonged and repeti- 
tive minor trauma such as a recent (19th century) military, young 
adult group under heavy stress. By law Renaissance youths initiated 
longbow training (which placed a 3(X)-pound pressure on each 
shoulder) at age of six years. It is conceivable that application of 
such stress to a growing bone may induce lesions to which a mature 
bone would be resistant. All agreed an investigational, radi- 
ologically based study on modern individuals with known, selected 
occupations could make a major contribution to the identification of 
osteologic lesions useful for prediction of handedness and occupa- 
tions. 



Zagreb Paleopathology Symp. 1988 



Methods 



Recovery of bone and serum proteins 

from human skeletal tissue: IgG, 

osteonectin, and albumin 

Noreen Tuross 



The most common substrates from which to infer or deduce 
vertebrate paleopathology are bones and teeth. Physical an- 
thropologists have explored the significant contribution that 
morphology and histology of mineralized tissues can make to 
our understanding of paleopathology. This study describes 
information at the molecular level that remains in the bones 
and teeth of some of our ancestors. 

The presence of amino acids in fossil bones and teeth was 
the first evidence that proteins indigenous to the animal 
might remain in the mineralized tissues (Abelson 1956; Ho 
1965). The preservation of the amino acids from the major 
bone protein, collagen, was documented in a variety of fos- 
sil bones from many locations (Ho 1965; Wyckoff and 
Doberenz 1965; Tuross and Hare 1978). In fossil bones much 
of the collagen exists as a heterogeneous mixture of degrada- 
tion products relative to the original gene product (Tuross et 
al. 1980). Isotopically. however, the degraded collagen is 
assumed to retain the pertinent information for archeometric 
use. Radiocarbon from collagen has been used to date fossils 
(Libby 1955; Taylor 1987) and the stable isotopes of carbon 
and nitrogen from bone collagen have been used in paleodic- 
tary interpretations (Schoeninger et al. 1983; Schoeninger 
and DeNiro 1984). Degradation of collagen, particularly the 
relative loss of the amino acid, glycine, can perturb the car- 
bon and nitrogen stable isotope values obtained from fossil 
bones and teeth (Tuross et al . 1 988 ). Better methods of isola- 
tion and characterization of proteins from fossil bones and 
teeth will contribute to the accuracy of archeometric isotopic 
applications. 

Many proteins other than collagen can be found in modern 
bone. Both scrum-derived and bone-cell-produced proteins 
can be extracted from bone. The complexity of the mixture of 
proteins found in bone can be seen in a two-dimensional gel 
electrophoresis analysis of bovine bone where approximately 
2(X) separate proteins were observed (Dclmas et al. 1984). 



Extraction techniques developed by John Termine and 
coworkers allow for the mineral and nonmineral associated 
proteins to be solubilized (Termine et al. 198 1 ). Five proteins 
from the mineral compartment of developing human bone 
have been purified and partially characterized (Fisher et al. 
1987). 

Of greatest potential interest to the paleopathologist is the 
preservation of serum-derived proteins in bone. Two serum 
proteins, albumin and alpha-2-HS. concentrate in bone and 
make up 13% of the noncollagenous bone matrix proteins 
extracted from fetal human subperiosteal bone (Robey et al. 
1988). Smaller amounts of many other serum-derived pro- 
teins, including transferrin and the immunoglobulins (IgG, 
IgA, IgM and IgE). can be isolated from modern bone. 

Noncollagenous proteins, osteonectin, albumin. IgG, and 
transferrin, have been identified at their original molecular 
weight in several individuals from the Windover archeologi- 
cal site in Florida. This 7000-year-old site, excavated under 
the direction of Glen Doran, yielded in excess of 150 human 
skeletons. The preservation of the mineralized tissue from 
the Windover site was variable. Generally, however, the neu- 
tral peat environment provided an anoxic, reducing atmo- 
sphere that was conducive to protein preservatit)n in these 
bones. 

This study examines the preservation of noncollagenous 
proteins — osteonectin, IgG, and albumin — in protein ex- 
tracts from human skeletal material excavated at the Sully 
and Mobridge sites in South Dakota. These cemeteries were 
excavated in the 1920s and the 1950s, and the collections 
reside in the National Museum of Natural History, Smithso- 
nian Institution. Associated materials al these sites date the 
skeletal remains at two to three hundred years of age. These 
skeletons are a classic museum collection, and provide the 
opportunity to assess the preservation of protein in bones that 
have been disinterred for 30 to 50 years. 



Zagreb Paleopathology Symp. 1988 



51 



52 • Noreen Tuross 



PROTEIN EXTRACTS 



A. 



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CO^ CO co^ 

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stained Partially 
Destained 

COOMASSIE 

Figure 1 . Protein extracts from three Mobridge site individ- 
uals on an SDS 4-20% polyacrylamide gel stained with 
Coomassie Brilliant Blue. Fully stained extracts are a smear 
of collagen degradation products over the entire molecular 
weight range of the gel. Equivalent extracts, partially de- 
stained in methanol/acetic acid/water, have discrete bands 
approximately 70 Ka and below. Multiple bands are apparent 
in each sample. Sharp, highly stained gashes above 97 Ka 
region are due to large amounts of protein (500 fig) applied to 
top of each lane. 

Materials and methods 

Thirteen rib fragments, weighing from 2 to 5 g, were taken 
from individuals (catalog numbers 325348, 325352- 
325358, 381159, 381163, 381193, 381342 and 381345, 
38 1 346) and extracted in 4M guanidine HC1/0.5M EDTA at 
4°C for two days. This procedure partially deriiineralized the 
samples. The guanidine/EDTA was removed from the sol- 
uble protein by desalting 35 ml of the solution over a P6DG 
column. The proteins were monitored at 254 nm, elutcd in 
100 mM ammonium acetate, and lyophilized. 

Fractions of the desalted protein were concentrated by 
Centricon (Amicon) filtration, and protein above 30,(X)0 mo- 
lecular weight retained on the filter was electrophoresed. 



Mini-gradient SDS gels. 4-20% acrylamide (Novex) were 
used in a traditional Laemmli (Laemmli 1970) buffer system. 
The gels were stained with Coomassie Blue, and partially 
destained for up to four days. 

Bacterial collagcnase (Advanced Biofractures) digestions 
of up to 1 mg of protein were done at 37°C for 4 to 8 hours. 
The fossil protein digests were then subjected to Centricon 
filtration with a membrane that would retain all proteins 
above 10,000 molecular weight. The filters were extracted 
with gel sample buffer and gel electrophoresed as described 
above. 

Electroblotting of collagenase digested proteins onto ni- 
trocellulose was performed according to the method of Tow- 
bin et al. (1979). Nitrocellulose electrotransfers were pro- 
cessed for immunodetection by using 1:1000 dilution of 
rabbit antihuman osteonectin and albumin (Cappel Laborato- 
ries) and a 1:2000 dilution of peroxidase conjugated goat 
antirabbit IgG (Kirkegaard and Perry Laboratories) and 
4-chloro- l-naphthol color reagent. IgG detection was 
achieved with a 1:1000 dilution of rabbit antihuman perox- 
idase conjugated IgG (Capell Laboratories). 

Results and discussion 

The protein extracts from all bone samples were collagen- 
like in their amino acid pattern. Gel electrophoresis (Figure 
1) of the whole protein extract gave a smear of Coomassie 
stainable material that ranged in molecular weight from 
> 200,000 to the 30,000 retained on the Centricon filter. 
This collagen smear is common in electrophoresed fossil 
bone extracts (Tuross et al. 1980) and results from multiple 
peptide bond breaks along the collagen molecule. Partial 
destaining of these Coomassie stained gels revealed the pres- 
ence of bands of protein originally obscured in the fully 
stained gel (Figure 1 ). 

The fully stained fossil protein extracts and the equivalent 
partially destained extracts are shown in relation to the pro- 
teins extracted by guanidine/EDTA in a modem human fetal 
calvarium. In modem bone, collagen is largely insoluble 
when subjected to the dissociative, demineralizing condi- 
tions of guanidine/EDTA (Termine 1983). In fossil bone, 
however, the partial breakdown of the collagen molecule 
renders this protein soluble to the same dissociative de- 
mineralizing conditions. 

This increased solubility of the collagen degradation prod- 
ucts makes the isolation and characterization of any remain- 
ing intact noncollagenous proteins or native collagen more 
difficult. Generally, large amounts of protein (up to 1 mg) 
from each skeletal sample must be applied to a gel in order 
to visualize any "bandable" protein upon partial destaining 
of a gel. Applying a large amount of protein to a gel can lead 
to several type of distortions, including the short, sharp, 
gashlike disconformities seen at the top of several lines in 
Figure I . 



Zagnb Paleopathology Symp. 1988 



Recovery of bone and serum proteins from human skeletal tissue • 53 



Allowing an electrophoresed total protein extract to par- 
tially destain after Coomassie Blue staining produced dis- 
crete bands of protein in 12 out of the 13 skeletal fragments 
analyzed. The number and the molecular weight of these 
bands varied among bone fragments, but generally, the most 
common band observed was at approximately 68 Ka. Several 
bands were also observed at 60 Ka, 45 Ka, and 42 Ka. The 
ability to see bands of protein as the collagen degradation 
products destain is due to the fact that collagen is a relatively 
poor Coomassie binder. Therefore difi'erent bands could be 
observed at varying stages of the destaining process, and any 
protein that binds Coomassie Blue equally or less well than 
collagen would not be seen at all. Another problem with the 
extensive collagen degradation products is the interference in 
transferring the fossil protein to nitrocellulose paper for im- 
munological detection. Because a percentage of the protein 
moves from the gel to the paper with time, it is difficult to 
transfer enough of the putative intact protein in a reasonable 
amount of time. 

The total protein extracts were digested with bacterial col- 
lagenase. Bacterial collagenase is an enzyme that degrades 
any string of amino acids, Gly-X-Pro or Hypro, to tripep- 
tides. Since only collagen has repeats of Gly-X-Pro or 
Hypro, this is the only protein that will be affected by the 
collagenase treatment. All of the skeletal fragments pro- 
duced protein that was partially degradable by bacterial col- 
lagenase, and all digested fossil bone protein extracts ex- 
hibited at least one Coomassie stainable band upon 
postdigestion electrophoresis (Figure 2). 

The ability to digest the background smear on the gels with 
bacterial collagenase is proof that the staining was caused by 
collagen breakdown products. The existence of Coomassie 
stainable bands after collagenase treatment is proof of the 
preservation of several noncollagenous proteins in these fos- 
sil bones. 

While preliminary identification of these bands can be 
made based on their molecular weight, immunological iden- 
tification by reacting the transferred bands to purified anti- 
bodies is the basic criterion upon which protein identification 
should be made. This immunodetection technique (com- 
monly called Western blotting) requires that one and only one 
band at the appropriate molecular weight recognize the anti- 
body being used. 

In preliminary analysis of the collagenase digested elec- 
trotransfers, the proteins albumin, osteonectin, and IgG were 
identified from these skeletal remains. Albumin was by far 
the most prevalent among the preserved noncollagenous pro- 
teins in the samples. The identification of IgG in some of the 
collagenase extracts demonstrates the ability to detect intact 
proteins from fossil extracts even in the absence of a clear 
Coomassie stained band on the gel. 

The demonstration of preservation of noncollagenous pro- 
teins in fossil bones that have been washed, treated and 
stored in a museum collection is an important addition to the 



COLLAGENASE 



B. 



oi 

c 

£ 

X 



lO r^ 00 

lO lO lO 
CO CO CO 

lo" in lo" 

CVJ C\J CM 
CO CO CO 



200K 1^1 


m 


■ 


116K^^^H 


1 


1 


97K^I^| 


1 


1 


66K ^r^" 


^ 


1 


42K H 


J 


^Sff 


31K m 







Figure 2. Bacterial collagenase digestion of bone protein 
from three Mobridge site individuals on an SDS 4-20% 
polyacrylamide gel stained with Coomassie Brilliant Blue. 
This is a fully stained (Coomassie) gel of protein bands re- 
maining after bacterial collagenase digestion of I mg of bone 
protein extract. The smear of degradation products from Fig- 
ure 1 is removed, and intact, collagenase-resistant proteins 
can be seen. A band just above the 66 Ka marker was positive 
to the rabbit antihuman albumin antibody upon electro- 
transfer, and two of the three individuals (325357 and 
325358) had bands that recognized rabbit antihuman os- 
teonectin antibody. 



growing evidence that fossil mineralized tissue contains mo- 
lecular information of importance to the paleopathologist. 
Digestion of fossil bone protein extracts with bacterial col- 
lagenase will increase our ability to screen these samples for 
molecular preservation. The preservation of immuno- 
globulins is particularly intriguing, and opens up the possi- 
bility that an independent record of disease states remains in 
the bones of many individuals. 



Zagreb Paleopathology Symp 19SS 



54 • Noreen Tuross 



Literature cited 

Abelson. PH. 1956. Paleobiochemistry. Scienlific American. 
195:83-92. 

Delmas. P.D., R.P. Tracy. B.L. Riggs, and K.G. Mann. 1984. 
Identitlcation of Noncoliagenous Proteins of Bovine Bone by 
Two-Dimcnsional Gel Electrophoresis. Calcified Tisstw Inicnui- 
tional, 36:308-316. 

Fisher, L.W., G.R. Hawkins, N. Tuross, and J.D. Termine. 1987. 
Purification and Partial Characterization of Small Proteoglycans 
I and II. Bone Sialoprotcins I and II. and Osteonectin from the 
Mineral Compartment of Developing Human Bone. Journal of 
Biological Chemislry: 262:9702-9708. 

Ho, T. Y. 1965. Amino Acid Composition of Bone and Tooth Pro- 
teins in Late Pleistocene Mammals. Proceedings of the National 
Academy of Science, 54:26-31. 

Laemmli. U.K. 1970. Cleavage of Structural Proteins during the 
Assembly of the Head of Bacteriophage T4. Nature. 227:680- 
685. 

Libby, W. 1955. Radiocarbon Dating. 2d edition. Chicago: Univer- 
sity of Chicago Press. 

Robcy. P.G.. L.W. Fisher, M.F. Young, and J.D. Termine. 1988. 
The Biochemistry of Bone. In B.L. Riggs and L.J. Melton, eds.. 
Osteoporosis: Etiology. Diagnosis and Management, 95-109. 
New York: Raven Press. 

Schoeninger, M.J., and M.J. DeNiro. 1984. Nitrogen and Carbon 
Isotopic Composition of Bone Collagen from Marine and Ter- 
restrial Animals. Geochimica et Cosmochimica Acta. 48:625- 
639. 

Schoeninger, M.J., M.J. DeNiro, and H. Tauber. 1983. Stable Ni- 
trogen Isotope Ratios of Bone Collagen Reflect Marine and Ter- 
restrial Components of Prehistoric Human Diet. Scieiwe. 
220:1381-1383. 

Taylor, R.E. 1987. Radiocarbon Dating: An Archaeological Per- 
spective. Orlando, Fla.: Academic Press. 

Termine, J.D. 1983. Osteonectin and Other Newly Described Pro- 
teins of Developing Bone. In W.A. Peck., ed.. Bone and Mineral 
Research, 144-156. Amsterdam: Excerpta Medica. 

Termine, J.D., A.B. Belcourt. KM. Conn, and H.K. Klcinman. 
1981 . Mineral and Collagen-Binding Proteinsof Fetal Calf Bone. 
Journal of Biological Chemistry. 256(20): 10403- 10408. 

Towbin, H., T. Staehilin, and J. Gordon. 1979. Electrophoretic 
Transfer of Proteins from Polyacrylamide Gel to Nitrocellulose 
Sheets: Procedure and Some Applications. Proceedings of the 
National Academy of Science, 76:4350-4354. 



Tuross, N.. D.R. Eyre, M.E. Holtrop, M.J. Glimcher. and P.E. 
Hare. 1980. Collagen in Fossil Bones. In P.E. Hare, ed.. Bio- 
geochemistry of Amino Acids, 53-63. New York: Wiley and 
Sons. 

Tuross, N., M. Fogel. and P.E. Hare. 1988. Variability in the Pres- 
ervation of the Isotopic Composition of Collagen from Fossil 
Bone. Geochimica et Cosmochimica Acta, 52:929-935. 

Tuross, N., and P.E. Hare. 1978. Collagen in Fossil Bone. Car- 
negie Institution of Washington Yearbook. 77:891. 

Wyckoff. R.W.G., and A.R. Doberenz. 1965. Electron Microsco- 
py of Rancho La Brea Bone. Proceedings of the National Acade- 
my of Science. 53:230-233. 



Summary of audience discussion: The ability to identify in ar- 
cheological human remains the serum antibodies present at the time 
of death would provide access to an incredibly valuable legacy of 
the history of specific infectious diseases suffered by an ancient 
population. However, it must be emphasized that demonstration of 
the presence of a major molecular IgG fraction does not guarantee 
that the variable end of the light chain is preserved well enough to 
reveal its immunologic specificity, which is necessary for identi- 
fication of the specific infectious agent against which the antibody is 
directed. Unfortunately the next analytical step in pursuit of that 
goal involves the use of chemicals strong enough by themselves to 
alter even the preserved protein. Recent studies on an excavated, 
150-year-old seaman of the mid- 19th century Franklin expedition, 
buried deep in North American arctic permafrost, demonstrated the 
research potential of cryopreserved bodies, but the surface arctic 
summer thawing conditions frustrate such efforts in most instances. 
Ancient tissues usually contain a host of polypeptides secondary to 
partially degraded protein, and the potential of these to react with 
immunological diagnostic reagents is untested. For this reason it 
appears desirable to include more controls than usual when applying 
such immunodiagnostic methods to archeological remains, and to 
be meticulously cautious in interpretation of their results. Investiga- 
tions leading to diagnostic security in the use of Immunological 
methods would be a major contribution to paleopathology. A recent 
Oxford conference presentation suggested the presence of protein 
within the hydroxyapatite crystals of fossil bone. The potential 
value of recovering intact protein there justifies serious research 
pursuit of that observation. 



Ziinnh Palenpalhology Symp 1988 



Bone histology and paleopathology: 
Methodological considerations 



Debra L. Martin 



In the last hundred years, identification and analysis of dis- 
ease processes have dramatically increased in the area of 
paleopathology. However, prior to the last ten years, analysis 
had remained primarily descriptive with the aim to identify 
disease in space and time. Recent emphasis on the interac- 
tions between biology and culture in the disease process has 
proven to be fruitful, yielding information concerning human 
adaptability within an evolutionary framework. A further 
expansion of the biocultural approach involves using skeletal 
material as an aid in elucidating processes and bone bio- 
dynamics in health and disease states. 

Given the interest in skeletal growth, pathology, mainte- 
nance, and repair, analyses should ideally proceed in a logi- 
cal and complementary fashion from the gross and mac- 
roscopic analysis to the histological and microscopic level. 
Building on this data base, the biochemical and molecular 
assays can follow. In this manner, identification of patholog- 
ic conditions, patterns of growth and development, changes 
in gross morphology, and alterations in the rate of morbidity 
and mortality can form the contextual framework for the 
other types of analyses. While emphasis on gross mor- 
phological features and measurements remains important to 
the reconstruction of human paleobiology and population 
success in adjusting to the physical environment, evidence 
now exists that other skeletal parameters (such as histology) 
can offer valuable information on health status prior to death 
(Martin etal. 1985). 

Bone at the microscopic level can be used as a tool, that is, 
as a model system or biological "window" into the past giv- 
ing a view of earlier behavior and health of the skeletal sys- 
tem (Frost 1964). The objectives of paleohistological analy- 
ses are to assess bone remodeling activity for entire 
populations and to examine the association of remodeling 
with age, sex, stature, pathological conditions, and cultural 
affiliation. The bridging of macroscopic data with micro- 
scopic data is seen as an essential step toward addressing 
differential health status across age, sex and culture. Tech- 
niques used by anthropologists must be based on biomedical 



precedents which are most applicable to archeological speci- 
mens. These techniques should include measure of bone 
quantity (cortical thickness, cortical area, and rate of re- 
modeling) and hone quality (quantification of the size, dis- 
tribution, and level of mineralization of discrete units of 
bone). These measures need to be based on well-defined 
skeletal parameters which are accurate, replicable. and use- 
ful in comparative analyses. 

Examplesofthetypesof multidimensional analyses which 
utilize histology include assessment of male and female dif- 
ferences in bone maintenance, correlation of macroscopic 
features of bone with microscopic features such as growth 
arrest, identification of subgroups at risk with respect to 
problems in bone metabolism, the effect of changing levels 
of sociopolitical organization and nutrition on health, and the 
effects of agricultural intensification on growth and develop- 
ment. 

Given what is currently known concerning the relationship 
between structural and physiological functions of bone, opti- 
mal conditions for normal growth and development can be 
hypothesized. These optimal conditions include adequate 
nutrition, low disease stress, proper endocrinological func- 
tion, and normal age-related wear and tear on the skeletal 
system. If these conditions are not met, the degree of dys- 
function which results will parallel the seriousness and dura- 
tion of the stressing agent (Ortner 1976). Analysis of health at 
the microstructural level can help define not only the exis- 
tence, but al.so the severity, of stress in individuals with al- 
tered physiological states. Health information gained in this 
way can be assessed in conjunction with information from 
other areas, such as the archeological data. The comprehen- 
siveness of the data will allow interpretations about the bio- 
logical evidence of health, the archeological reconstruction 
of ecological and cultural variables, and the demographic 
profiles resulting from accumulated morbidity and mortality 
at the population level. 

Loss of bone (osteopenia) and lack of bone mineralization 
(osteoporosis) arc the two most important responses that 



Zagreb Ptileopalhology Symp. I9SS 



55 



56 • Debra L. Martin 



skeletal tissue makes when under physiological stress. Gross 
pathologic changes on bone reveal insults to which an indi- 
vidual may have been subjected such as infectious disease, 
trauma, and degenerative changes such as arthritis. Tradi- 
tionally, the health status of prehistoric individuals was based 
on these gross indicators alone. The analysis of bone his- 
tology provides information on a more subtle level — 
information concerning chronic or episodic undernutrition, 
periods of physiological disruption which leave no trace on 
the outer skeletal surfaces, the long-term effects of multi- 
parity and lactation on female calcium metabolism, and the 
effects of immobilization on skeletal health. 

In summary, analysis of physiological aspects of skeletal 
remodeling provides a clue to an individual's lifestyle, diet, 
reproductive activity, and nutritional adequacy. These in- 
dicators of health are rarely "clinically" significant; they re- 
flect the day-to-day physiological responses which individu- 
als must make. It is these responses at the histological level 
on which current research can focus. 

Bone biodynamics 

A general familiarity of normal bone histology, as well as the 
normal processes involved with growth, development, main- 
tenance and repair, is necessary in order to highlight and 
understand the range of possible responses bone can make 
when experiencing physiological stress. Bone is a highly 
specialized kind of connective tissue and it is distinguished 
from other tissues such as skin and cartilage by its hard and 
crystalline structure. Bone has a cellular matrix composed of 
collagen and protein fibers embedded in a ground substance 
high in mucopolysaccharides. The hardness of bone comes 
from crystalline salts of calcium, phosphate, and carbonate 
deposited within the organic matrix. Specialized cells medi- 
ate the deposition and withdrawal of the mineral component 
of bone to keep an even balance between the body fluids and 
the skeletal reserves (Raisz and Kream 1983). Bone exists in 
a dynamic equilibrium with blood, and the "bone-body con- 
tinuum" is regulated by nutrients and hormones (McLean and 
Urist 1968). 

Much of the outward appearance, and most of the histo- 
logical aspects of bone reflects the biological responses to 
physical and structural requirements. The diverse set of func- 
tions which a skeletal system provides (for example, struc- 
tural support, locomotion, storage and regulation of miner- 
als, control of ionic concentrations in body fluids, and 
production of red blood cells) necessitates a high priority for 
maintenance. Thus, as a connective tissue, bone is an open 
and living system which changes constantly throughout life 
to meet the demands for growth, development, maintenance 
and repair. 

Disturbance in normal patterns of growth, mineralization, 
and remodeling form the pathogenesis of nutritional, hormo- 
nal, disease and aging problems (Jowscy 1964). These pro- 
cesses can be measured, and the values can be used to define 



boundaries between health and disease. Quantification of 
histological properties of bone aids in making diagnoses and 
indicates the probabilities that the properties of an individual 
case are within healthy or diseased states (Byers 1977). 

Osteons are discrete units of bone which are the major 
quantifiable histological features used in diagnostic analy- 
ses. In the femur, osteons measure approximately 0.25 mm 
in diameter and are easily viewed under low or high magni- 
fication. Osteons take a variable length of time to form. In a 
ten-year-old individual osteons take 46 days to attain com- 
pleteness and full mineralization. In a 60-year-old, osteons 
can take as long as 108 days to attain completeness (Lips et 
al. 1978). 

Both complete osteons and partial osteon fragments re- 
main visible for many years, since at any given time only 3- 
5% of the skeleton of an individual undergoes active re- 
modeling during adulthood (Frost 1964). Osteons, resorption 
spaces, fragments, and layers of bone without osteons 
(lamellae) play a central and critical role in maintaining the 
quality and quantity of bone. 

Once bone has been shaped by growth, it can be altered by 
the remodeling process, or "turnover" of bone (Frost 1973). 
There is activity of some degree in every part of the skeleton 
throughout life. The two basic components of this process are 
formation of osteons and resorption of older osteons. Re- 
modeling is the resorption of older units of bone and forma- 
tion of and replacement with newly mineralized bone. Re- 
modeling can be viewed as quantitative changes in osteonal 
size, degree of mineralization, and placement within the cor- 
tex of bone. 

Resorption and formation are not independent phenome- 
na; they are coupled. After each resorption activity, there is 
always a formation activity although the rate is variable. The 
cycle of resorption and subsequent formation can take from 
three months to one year (Frost 1969). The formation/ 
resorption ratio is a relative indicator of how many cycles are 
in progress, but does not indicate at what point the cycles are, 
or if the cycles are proceeding normally. 

Although remodeling continues at predictably different 
rates in each decade of life, the consequence is an ever- 
increasing population of osteons per unit volume of cortical 
bone. Remodeling occurs slowly enough that previously re- 
modeled bone remains unchanged for long periods of time. 
The actual rate of remodeling can be measured by comparing 
the number of older bone units with that of newer bone (Frost 
and Villanueva 1960; Jowsey 1964) or by determining the 
amount of bone laid down over the course of the life span 
(Frost and Wu 1967). 

A healthy individual weighing 72 kg has approximately 14 
kg of skeletal tissue. Of that 14kgofbone, half is composed 
of calcium (Posncr 1979). Calcium is extremely important to 
the biochemical constitution of skeletal tissue. Approxi- 
mately 99% of the calcium ingested from food goes directly 
to the skeletal tissue; only 1% of the calcium remains cir- 
culating in the blood (Raisz 1977). The small percentage of 

Zagreb Paleopalholdity Symp. I91IH 



Bone histology and paleopathology: Methodological consi derations • 57 



calcium in the circulatory system is crucial for the mainte- 
nance of cardiac and nervous system function (Marshall et al. 
1976). 

In summary, diet, disease, and aging are all factors which 
affect calcium metabolism and bone remodeling, and these 
are especially valuable variables to track in prehistoric skele- 
tal populations. This brief summary of bone dynamics serves 
to highlight the complexity of bone as a tissue and, more 
importantly, to suggest the ways in which the .skeletal system 
responds to physiological disruption and the ways that this 
response can be reconstructed from the histological proper- 
ties. Skeletal remodeling provides a measure of skeletal 
health as well as an indication of the health of the individual 
as a whole. Of particular mterest to this research is that 
skeletal remodeling presents an ideal form of evidence lead- 
ing to an understanding of prehistoric health. By understand- 
ing the physiological properties of skeletal remodeling, a 
clearer and more realistic reconstruction of past health can be 
made. 

Response to stress on a histological level 

Bone tissue is most affected by three factors: aging, disease, 
and nutrition (Smogyi and Kodicek 1969). Of particular sig- 
nificance to anthropological research is the fact that bone 
microstructure is sensitive to these factors, and tissue at the 
microstructural level is frequently preserved in archeological 
specimens (Stout 1978). 

Bone reacts to stress in a limited number of ways. In 
general, the skeletal response to physiological stress is one 
(or a combination) of three phenomena: ( 1 ) reduced bone 
mass, (2) increased bone mass, and (3) poorly mineralized or 
abnormal bone quality (Meunieretal. 1979). It is the type of 
response, the timing of onset, the degree of severity, the 
pattern, and the frequency of abnormal histological proper- 
ties which aid in the interpretation of remodeling. 

It is a well-documented fact that structural and physical 
responses of bone to biological needs are affected by the 
aging process (Kerley 1965). A knowledge of normal, age- 
related processes in bone represents a factor critical to the 
understanding of pathological or abnormal conditions. One 
important distinction to be able to make when dealing with 
bone loss is the one between loss due to old age and loss due 
to other factors such as disease, malnutrition, or hormonal 
imbalances. Clinical methods for delineating bone loss as a 
function of age and other factors are outlined in Barzel 
(1979), Fro.st (1973), Jaworski (1973), and Simmons and 
Kunin(l979). 

Skeletal remodeling can also be significantly altered by 
insufficient nutrients. Theeffectsof nutrient deficiencies can 
be compounded not only by inadequacies in the diet, but by 
further problems in malabsorption of nutrients in the system. 
Experimental studies on animal models have shown the 
effects of protein-caloric malnutrition to be systemic and 
generalized (Steward 1975). During protein-calorie mal- 

Zagnb Paieopalhotogy Symp. 1988 



nutrition growth slows or ceases, remodeling rates increase, 
and removal of bone exceeds deposition with mineralization 
of existing bone greatly slowed (Dickerson and McCance 
1961). 

Studies conducted on clinical populations experiencing 
nutritional stress support the findings that a general sequence 
of events are followed. These include ( 1 ) retardation in long 
bone growth and delayed maturation for children, (2) slowed 
formation of new bone for adults and children, and (3) exist- 
ing bone loss by resorption with a net decrease in bone mass 
(Gam 1970). 

While bone loss can be viewed as a pathological condition, 
it is important to note that the loss can also be seen as an 
adaptive response under certain circumstances such as nutri- 
tional stress. In the face of protein-calorie malnutrition or 
deficiencies in minerals, skeletal reserves can be used for 
growth, repair or function. 

Rather than searching for a single diagnostic criterion, 
patterns of bone growth and maintenance must be examined 
with the emphasis on stress markers at the different stages of 
skeletal activity throughout the life cycle. Remodeling ac- 
tivities need to be carefully examined in conjunction with 
other variables such as age, sex, and pathologic conditions in 
order to interpret the nature and severity of nutritional stress. 

Use of histology in anthropological research 

As early as 1 849, researchers were looking at microstructure 
of fossils, and in 1878 an extensive histological analysis of 
fossil bone and teeth demonstrated that histological struc- 
tures were preserved in archeological specimens (Stout and 
Simmons 1979). Advances in technology led to a further 
understanding of the extent to which skeletal histology is 
preserved. Archeological specimens of varying age and from 
differing soil types and differing degrees of moisture ex- 
posure have been compared at the histological level for pres- 
ervation. Race and co-workers (1968) found that the greatest 
alteration in skeletal material due to weathering was chemi- 
cal in nature (not structural), and that osteons were often 
visible even in samples where severe chemical diagenesis 
had occurred. 

During the early 1900s, attempts to detect abnormalities in 
preserved skeletons increased along with the methods used to 
assess pathological conditions (Brothwell and Sandison 
1967). The development of radiographic techniques and the 
application to prehistoric specimens by Moodie (1923) made 
substantial progress in paleopathological research. Moodie 's 
work often used histological sections, although analysis of 
the sections was not based on quantifiable measures. In spite 
of these early ob.servations of morphology, no systematic 
analysis of histological structures was performed. Putschar 
stated, "one should not. however, expect too much help from 
the microscopic examination . . . since diagnostic micro- 
scopic bone patterns arc rare" and he further emphasized that 
"gross examination of the surface is more important" 



58 • Debra L. Martin 



(1966:58-59). This lament has perhaps inhibited the growth 
of histological studies on prehistoric skeletal material, but 
the overwhelming success of more recent studies should put 
that attitude to rest. 

Numerous methods have been developed to evaluate the 
absolute amount of bone present. One noninvasive technique 
used is photon absorptiometry. Perzigian (1973) used this 
technique to test the hypothesis that change in diet affected 
the rate of bone loss. Greater bone loss was found to occur in 
the agricultural group than in the gathering and hunting 
groups in an archeological population from Indian Knoll. 

Stout and Teitelbaum ( 1976) offer one of the first detailed 
methodological considerations on both how to prepare and 
how to analyze a prehistoric thin section of bone. Practical 
information concerning embedding, staining, and mounting 
sections is reviewed. The authors suggest numerous avenues 
of potential research for the use of bone in the assessment of 
health and disease. Ortner (1976) also presents a review of 
the potential application of bone histology to ancient skeletal 
remains. This study emphasizes the ability of histological 
properties to give an indication of the aging process, nutri- 
tional adequacy, and disease status of prehistoric individuals. 
Martin and co-workers (1985) present a thorough review of 
the anthropological literature on methods for assessing quali- 
ty and quantity of diet through the use of histological analy- 
sis. 

An analysis of skeletal remodeling activity was under- 
taken for two Illinois Woodland populations representing the 
shift from intensive, harvest-collecting subsistence to that of 
com agriculture (Stout 1976). Thin sections of rib were used 
and turnover rates were calculated, based on the density of 
remodeled osteons, to estimate actual amounts of bone for- 
mation per year in square millimeters for each individual. 
The results indicated a tendency toward increased bone re- 
modeling rates in the agricultural population. The author 
suggested several possibilities for this, with dietary inade- 
quacies serving to explain the findings best. 

Patterns of remodeling have also been determined from 
microradiographs of femoral cross-sections. Martin and Ar- 
melagos (1979) combined cortical thickness and area mea- 
surements with histological analysis of osteons to examine 
bone loss and maintenance for an adult population from pre- 
historic Sudanese Nubia. Nubian females exhibit early and 
dramatic rates of bone loss on the organ level. Analysis of the 
distribution of osteons and the rate of ostconal remodeling 
further showed the differences between age-matched males 
and females. A diet low in calcium, iron, and protein, com- 
bined with endemic parasitic infestations, and the increased 
metabolic demands of reproduction created a negative skele- 
tal balance for young adult Nubian females (Martin and Ar- 
melagos 1985). 

Weinstein and co-workers ( 1 98 1 ) studied the histology of a 
Peruvian mummy and found that the histomorphometrics 
were profoundly dissimilar from normal parameters. The 



researchers concluded that an imbalance between bone for- 
mation and resorption was the result of a dietary stress. 
Thompson and Gunness-Hey (1981) used microstructural 
analysis to examine bone loss in Kodiak Island Eskimo popu- 
lations. Pfeifter (1981) and Pfeifter and King (1981) used 
osteon counts of prehistoric Canadian populations to analyze 
age structure and health. 

Richman and co-workers ( 1979) looked at osteonal varia- 
tions in Eskimo, Pueblo, and Ankara prehistoric popula- 
tions. They were able to document a significant increase in 
the number of growth-arrested osteons in the Eskimos, and a 
dietary explanation was postulated. 

In summary, the systemic and general nature of human 
skeletal response to stress has been profitably used on pre- 
historic remains to interpret the nature of the stressing agen- 
cies involved via examination of patterns of bone growth, 
remodeling, repair, and loss. The occurrence of physiologi- 
cal disruptions at different parts of the life cycle can be exam- 
ined and compared to the mortality rates of the group. Infor- 
mation from indirect and direct examination of skeletal 
remains has been combined with environmental data to pro- 
vide a more realistic reconstruction of the nutritional and 
health status of prehistoric groups. 

Conclusions 

In this brief and select overview of the anthropological uses 
of bone histology, there is ample evidence suggesting that 
analysis of bone histology can reveal information which far 
surpasses information obtained from macroscopic analyses 
only. Aging, disease, and nutritional stress are the main 
categories which can be tracked using histological analysis. 
Given that these categories are precisely those used to recon- 
struct the health dynamics of prehistoric peoples, it seems 
timely for histology to enter the mainstream of skeletal analy- 
ses in anthropology. For archeological populations, the as- 
pect of nutritional and disease stress in endemic or epidemic 
conditions holds the most potential for interpreting pre- 
historic adaptation. 

The use of histological analysis can highlight individuals 
who are experiencing health problems but who do not show 
gross pathologic changes. Further, subgroups within the pop- 
ulation can be identified who are most sensitive to stresses 
which affect skeletal health, and by extension, stresses which 
affect overall patterns of morbidity and mortality. 



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Stratton. 
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Springfield. III.: Charles C Thomas. 
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Bone histology and paleopathology: M ethodological considerations • 59 



236. New York: Academic Press. 

Dickerson. J.W.T.. and R.A. McCance. 1961. Severe Undernutri- 
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Frost. H.M. 1964. Dynamics of Bone Remodeling. In H.M. Frost, 
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Frost. H.M., and A.R. Villanueva. 1960. Measurement of Os- 
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Frost. H.M.,andK. Wu. 1967. Histological Measurements of Bone 
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Kcrley. E.R. 1965. The Microscopic Determination of Age in Hu- 
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Lips. P.. P.J. Munier. and P. Courpron. 1978. Mean Wall Thickness 
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Marshall. D.H.. B.E.C. Noirdin. and R. Speed. 1976. Calcium. 
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Martin, D.L.,andG.J. Armelagos. 1979. Morphometries of Com- 
pact Bone: An Example from Sudanese Nubia. American Journal 
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1985. Skeletal Remodeling and Mineralization as Indica- 
tors of Health: An Example from Prehistoric Sudanese Nubia. 
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Martin, D.L., AH. Goodman, and G.J. Armelagos. 1985. Skeletal 
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Mielke and R. Gilbert, eds.. The Analysis of Prehistoric Diets. 
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McLean, F.C., and M.R. Urist. 1968. Bone: Fundamentals of the 
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Meunier. P.J., P. Courpron, J.M. Geroux, C. Eduoard, J. Bernard, 
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Moodie, R.L. 1923. Paleopathology. Urbana: University of Illinois 
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Ortncr. D.J. 1976. Microscopic and Molecular Biology of Human 
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Physical Anthropology, 20:35-44. 



Perzigian. A.J. 1973. The Antiquity of Age-Assoeiated Bone Loss 
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Pfeiffer, S. 198 1 . Bone Remodeling Age Estimates Compared with 
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794. 

Pfeiffer. S.. and P. King. 1981 . Intracortical Bone Remodeling and 
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Posner, A. 1979. The Relationship Between Diet and Bone Mineral 
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New Haven, Conn.: Yale University Press. 

Race, G.J., E.L Fry, J.L. Mathews, H. Martin, and J. A. Lyon. 
1968. The Characteristics of Ancient Nubian Bone by Collagen 
Content and Light and Electron Microscopic Examination. Clini- 
cal Pathology. 45:704-713. 

Raisz, L.G. 1977. Bone Metabolism and Calcium Regulation. In 
A. Avioli and D. Krane, eds.. Metabolic Bone Disorders, llli- 
230. New York: Grune and Stratton. 

Raisz, L.G. , and B.E. Kream. 1983. Regulation of Bone Formation 
(XanAW). New England Jounuil of Medicine. 2,m:29-l>5.%'i-?,9. 

Richman, G.A., D.J. Ortner, and F.P. Schulter-Ellis. 1979. Differ- 
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Simmons, D.J., and A.S. Kunin. 1979. Skeletal Research. New 
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Smogyi, J.C, and E. Kodicek, eds. 1969. Nutritional Aspects of 
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Stout. S.D. 1976. Histomorphomctric Analysis of Archaeological 
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1978. Histological Structure and its Preservation in An- 
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Stout, S.D., and S.L. Teitelbaum. 1976. Histological Analysis of 
Undecalcified Thin Sections of Archaeological Bone. American 
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Thompson, D.D., and M. Gunness-Hey. 1981. Bone Mineral Os- 
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Physical Anthropology. 55: 1 -7. 

Weinstein, R.S., D.S. Simmons, andC.O. Lovejoy. 1981. Ancient 
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Summary of audience discussion: In response to the question of 
the role of estrogen in bone remodeling, it was suggested that the 
hormone has a stimulating effect on endosteal osteoblasts and that 
grand multiparas tend to have thicker bones, although prolonged 
lactation may deplete bone mineral content. 



Zagreb Paleopathology Symp. I98ii 



8000-year-old brain tissue from the Windover 

site: Anatomical, cellular, and 

molecular analysis 



William W. Hauswirth, Cynthia D. Dickel, Glen H. Doran, Philip J. Laipis, 

and David N. Dickel 



The Windover site (8BR46) consists of a small (5400 m^) 
peat deposit in a low-lying swale on the western edge of the 
Florida Atlantic Coastal Ridge, roughly equidistant from the 
Indian River coastal lagoon system and St. John's River in 
eastern, central Florida (Figure 1). Information from pre- 
liminary analysis of flora and fauna indicates the site was a 
wooded marsh from 8000 b.p. to 6900 b.p. and during this 
time was regularly used as a burial ground. Most bodies 
found at the site had been placed in a flexed position and then 
buried lying on their sides in anaerobic, water-saturated peat 
at an approximate depth of one meter. 

The Windover site is a significant North American archeo- 
logical site for several reasons: it is one of the oldest Ameri- 
can sites with a large, representative human skeletal sample; 
it contains all age morphs; it has a large sample of prehistoric 
flexible fabrics; it has 91 crania containing preserved matter 
identifiable as brain tissue; and intracranial tissue was dem- 
onstrated to be human by cellular and biochemical tech- 
niques and by isolation of human DNA (Doran et al. 1986). 

Results 

RADIOCARBON DATES 

During excavation four distinct types of peat strata were 
identified (Figure 2). The upper stratum (1.2 m thick) was 
composed of black sawgrass-peat (W. Spackman, Jr., andS. 
Stout, pcrs. comm. 1986). The lower levels of this black peat 
were dated at 4790± 100 b.p. (Beta- 10763). Underlying the 
black peat was a 1 .2-m-thick stratum of red-brown peat con- 
taining a high concentration of naturally deposited wood. 
The upper zone of this red-brown peat has been radiocarbon 
dated at 5800±80 b.p. (Beta- 10764). The red-brown peat 



stratum had a striking preservation of intact leaves, sawgrass 
strands, twigs, branches, turtle bones, fish remains, nonhu- 
man fecal material and other faunal material. The highest 
concentration of skeletal material was within the lowest lev- 
els of the red-brown peat stratum. Underlying the red-brown 
peat was an approximately 0.5-m-thick layer of "rubber" 
peat. The top of the rubber peat stratum has been radiocarbon 
dated at 7950 ± 140 b.p. (Beta- 10855). Human and nonhu- 
man skeletal material and preserved wood decreased with 
increasing depth of the rubber peat. The incidence of fresh- 
water moUusks was high in the rubber peat and may have 
influenced the water chemistry of the pond. Beneath the 
rubber peat was a I.8-m-thick stratum of tan-brown peat 




xlx 


8b£ 


246; 



2S0KII1. 

Scale 

(Excluding intel) 



Figure I . Geographic location of the Windover site, 
8BR246 



60 



Zagreb Paleopathology Symp 1988 



MAX. DEPTH 
POND WATER 



BLACK PEAT 
(SAWGRASS PEAT) 



RED BROWN PEAT 
(UPPER ZONE) 



RED BROWN PEAT 

(LOWER 70NF1 



■RliBBIR" PEAT 



TAN-BLACK PEAT 
(WATER-LILY PEAT) 



Analysis of 8000-year-old brai n tissue from t he Wind ov er si te • 61 



RADIOCARBON DATES 



4790 ± 100 B. P. 



5800 -t 80 B. P. 



7360 ± 70 B. P. 



tinman 
bone conccniralion 



7950 ± 140 B.P 



10, 160 •: 120 B.P 



Table L Cu lturally relevant radiocarbon dates 

Dat^ Sample Laboratory 

number 



6980 ±90 Wooden stake Beta- 19316 

7050 ±80 Peat near highest bone Beta-14132 

6990 ± 70 Human bone (AMS) TO-207 

7100 ±100 Wooden stake Beta-19315 

7210 ±80 Human bone Beta-7186 

7290 ± 120 Bottle gourd Beta-20450 

7300 ±70 Wooden stake Beta- 19722 

7330 ± 100 Human bone Beta-5803 

7360±70 Peat beneath crania Beta-11381 

7410 ±80 Peat from brain surface Bela-11383 

7830 + 80 Human bone (AMS) TO-518 

7930 + 80 Wooden stake Beta- 18295 

8120 ± 70 Human bone (AMS) TO-241 

8430 + 100 Peat at base of Beta- 13909 
red-brown strata 



a. Date in radiocarbon years B.P. 



GREY SAND 



maximum depth of grey sand not determined 

Figure 2. Stratigraphic profile, peat types, and uncorrected 
radiocarbon dates on peat from the Windover site, 8BR246. 
Radiocarbon dating either by Isotrace Laboratory, University 
of Toronto, Canada, or by Beta Analytical, Coral Gables, 
Florida. Sample numbers indicated in text (e.g.. Beta 
10763). Dates in years b.p. Correction factor of +800 yrB. p. 
should be added to dates between 7000 and 10,000 yr b.p. 
(Klein et al. 1982). MAMASL. meters above mean annual sea 
level. Vertical scale units, 20 cm. 

containing no freshwater mollusks or human bone. This stra- 
tum has been described as water-lily peat (W. Spackman, Jr. . 
and S. Stout, pers. comm. 1986) and radiocarbon dated at 
over 10,000 years. Underlying the entire deposit was a gray 
Pleistocene sand. 

The chronometric placement of Windover skeletal mate- 
rial is based on a series of radiocarbon dates (Table 1 ). These 
dates were obtained directly from human bone, from the top 
and bottom of vertical burial stakes, peat above, within, and 
beneath human bone, and from multiple locations within the 
pond. Recent radiocarbon corrections (Beukens 1986) indi- 
cate the dates would cluster the human activities at Windover 
at approximately 7450 b.p. The radicKarbon dates place the 
utilization of Windover in a chronological period that is usu- 
ally considered Early Archaic in the southeastern United 
States (Milanich and Fairbanks 1980). 



CULTURAL MATERIALS 

The Windover burials were accompanied by a diverse cultur- 
al inventory. Artifacts fabricated from animal teeth, antler, 
bone, seed, wood, shell and stone were found. Bone awls 
and pins were the most commonly recovered artifact catego- 
ry and were manufactured from upland game including deer, 
canids, and felids. Drilled antler and manatee ribs and atlatl 
cups were also found. A bottle gourd (Lagenaria siceniria) 
accompanying a burial provides early evidence of curcurbits 
north of Mexico; it predates other Lagenaria and virtually all 
other known Curcurbitacae north of Mexico (Conrad et al. 
1984; Kay et al. 1980; Prentice 1986). The status and mor- 
phology of the specimen is being carefully evaluated particu- 
larly in light of its early context (Newsom 1987). 

Additionally, textile materials were recovered from 37 of 
the burials. Seven twining/weaving variants have been iden- 
tified which include fine-balanced, plain-weave inner gar- 
ments, more durable complex-twined materials possibly rep- 
resenting blanketlike items, twined globular bags, open- 
twined items and matting (Andrews and Adovasio 1988). 
Macroscopic and microscopic thin sections of plant fibers in 
the fabrics have been unsuccessful in identifying the plant 
species utilized. Morphological features that would normally 
prove taxonomic criterion were apparently removed during 
the original processing of plant fibers or simply have not been 
preserved for 8(X)0 years (Andrews and Adovasio 1988; 
Newsom 1987). Phytolith studies also failed to provide infor- 
mation for the identification of plant fibers (Pipemo 1987). 



Zagreb Paleopathology Symp 1988 



62 • W.W. Hauswirth, CD. Dickel, G.H. Doran, P.J. Laipis, and D.N. Dickel 



Table 2. North American material with firm dating in excess of 6500 radiocarbon years B.P. (uncorrected) 



Provenience 


Dal^ 


Sample 
size 


Reference 


Republic Groves, FL 


6520-5745 


37 


Wharton et al. 1981 


Bay West, FL 


6630 +80 


30-45 


Beriault et al. 1981 


Carrier Milles, IL 


6750-5650 


159 


Bassett 1982 


Union Lake, MI 


7000 +400 


1 


Black and Eyman 1%3 


Eva, TN, Stratum IV 


7150 +500 


17 


Lewis and Lewis 1%1 


Tecolote Point, CA 


7230-3970 


79 


Berger et al. 1971; Protsch 1978. 


Glen Annie, CA 


7400-6700 


7-8 


Owen 1964. 


Angeles Mesa, CA 


7900-4050 


6 


Taylor et al. 1985 


Modoc Rock Shelter, CO 


7970-6219 


24 


Neumann 1%7 


Batiquitos Lagoon, CA 


8000 +3000 


9 


Bada 1985; Bada and Helfman 1975 


Scripps Estates, CA 


8000-4820 


2 


Taylor et al. 1985; Bada 1985 


San Diego series, CA 


8100-5000 


46 


Bada and Helfman 1975; 
Ike et al. 1979; Protsch 1978 


Windover, FL 


8120-6990 


172 




Sunnyvale, CA 


8200-3600 


1 


Bada and Helfman 1975; Taylor et al. 1985 


San Diego, CA 


8360 +75 


1 


Ike et al. 1979 


(SDM 16709) 








La Brea, CA 


9000-4450 


1 


Taylor et al. 1985 


Renier, WI 


9524-6300 


1 


Mason and Irwin 1960 


Cutler Ridge, FL 


%70 + 130 


5 


Carr 1987 


Gordon Creek, CO 


9700 +250 


1 


Breternitz et al. 1971 


Arlington Springs, CA 


10000 +200 


1 


Protsch 1978 


Horn Shelter, TX 


10310 +150 


2 


Young 1985, 1986 


Sulphur Springs, AZ 


10420-8200 


1 


Waters 1985, 1986 


Mostin, CA 


10470-4000 


1 


Kaufman in Taylor et al. 1985; Young 1986 


Warm Mineral Springs, FL 


10500 +1700 


21 


Clausen et al. 1975; Lien 1983 


Anzik/WUsall, MN 


10600 +300 


1 


Taylor 1%9 


Marmes Rockshelter, WA 


10750-6200 


28 


Sheppard et al. 1987 


Fishbone Cave, NV 


11200-10900 


1 


Young 1986 


Wilson-Leonard, TX 


13000 +3000- 


9470 1 


Weir 1985 


Midland, TX 


13400-7100 + 


1000 1 


Wendorf et al. 1955 



Note: The age range and sample sizes are listed when possible 
a. Date in radiocarbon years B.P. 



OSTEOLOGICAL MATERIAL 

Few large samples of human skeletal material earlier than 
6500 B.P. have been recovered from New World deposits 
(Table 2). Therefore, the Windover collection provides an 
opportunity for detailed analysis of such a population. Data 
currently being obtained includes general nonnietric, metric 
and morphological features, disease morbidity, age, sex and 
other paleodemographic features. The abundant subadult 
material (52%) provides an excellent opportunity lor the 
study of growth and development in this population. 



Some initial data on the skeletal materia! has been re- 
ported. Preliminary evidence for nutritional/metabolic stress 
based on transverse lines, cribra orbitalia, enamel defects 
and cranial hyperostosis has recently been summarized 
(Dickel 1986). Interproximal grooves have been described 
and compared to similar dental modifications found in other 
prehistoric populations (Dickel in press). A case of severe 
lumbar spina bifida aperta complicated by scoliosis has also 
been reported (Dickel 1987; Dickel and Doran 1989). This 
case shows strong evidence of sensory loss in the lower limbs 
including the loss of the distal tibia due to a massive infec- 
tious lesion. 

Zagreb Paleopalhulnny Symp. I9IIH 



Analysis of 8000-year-old brain tissue from the Windover site • 63 



Table 3. Water chemistry of the Windover site (mg/1) 

Laboratory Number 

878SP S79f 10604= 10491"^ 



Calcium 


160.0 


81.5 


94.0 


4.0 


Magnesium 


77.0 


60.5 


68.0 


4.6 


Total dissolved solids 


1447.5 


1420.0 


1418.0 


170 


Total hardness 


716.4 


452.5 


27.5 


28.8 


Carbonate hardness 


31.2 


8.9 


ND 


0.1 


Noncarbonate hardness 


685.2 


443.6 


527.5 


28.8 


Total alkalinity 


31.2 


8.9 


498.2 


0.1 


Bicarbonate 


31.2 


8.9 


ND 


2 


Carbon dioxide 


38.1 


34.3 


6.4 


1.87 


Total phosphate 


0.99 


0.01 


ND 


ND 


Sulfides 


ND 


1.6 


0.05 


0.04 


Chlorides 


189.0 


472.4 


ND 


ND 


Strontium 


4.3 


2.3 


4.8 


0.27 


Sulfates 


381.9 


33.9 


ND 


ND 


Fe 


9.3 


35.5 


ND 


ND 


Mn 


0.105 


0.01 


ND 


ND 


Cu 


1.38 


0.03 


ND 


ND 


Zn 


0.06 


0.17 


ND 


ND 


K 


6 


26.0 


ND 


ND 


Na 


200 


350.0 


ND 


ND 


PH 


6.1 


5.6 


6.9 


2.9 



a. Water standing in Windover pond prior to excavation 
or wellpointing. This represents percolation of waters 
from the peat deposits with some mixture of surface 
runoff and rainwater. 

b. Wellpoint sample taken moments after 5 wellpoints 
vwere installed - this is probably the best estimate of the 
waters actually saturating the peat strata. 

c. Water seeping into one, of the deeper excavation units, 
it predominantly reflects the underlying waters with some 
mixture of the peat waters. 

d. Water from a nearby pond. 



WATER CHEMISTRY 

In contrast to a nearby pond. Windover water was substan- 
tially more mineralized with high amounts of calcium, mag- 
nesium, total dissolved solids, and sulfates (Flowers Chemi- 
cal Laboratory, Altamont Springs, Florida). Additionally, the 
pH of the Windover samples are generally closer to neutral 
than the nearby pond water samples (Table 3 ). 

Zagreb Paleopaihology Symp. I98X 




Figure 3. Lateral radiograph shows material that, 
though shrunken in comparison to the bone and 
settling toward the base, resembles the expected 
configuration of brain within the skull. This mass 
proved to be peat surrounding a residual brain . 

ANATOMICAL AND CELLULAR ANALYSIS 

Based on the number of adult crania and subadult crania and 
mandibles, at least 172 individuals were recovered from the 
Windover site. The recovered bone was well preserved and 
nonfriable. Ninety recovered crania contained soft tissue 
remnants, sometimes preserved as recognizable brains and 
sometimes as amorphous masses of brain tissue mixed with 
peat. Bone fragments from one of the crania containing a 
brain were dated at 6990 + 70 b.p. (Isotrace TO-207) by ac- 
celerator mass spectrometry (AMS) dating. 

Age and sex determinations based on cranial structure, 
dental attrition, and limited postcranial skeletal evidence in- 
dicated the two adult crania initially analyzed were from a 
female at least 45 years old and a male about 25 years old. 
When the female intracranial mass was removed, the imme- 
diate visual impression was of a human brain; however, it 
was extremely fragile, making handling difficult. Therefore, 
analysis of the male cranium was carried out by a non- 
invasive appraisal using conventional x-ray imaging, com- 
puterized axial tomography, and proton magnetic resonance 
imaging (MR). 

X-ray analysis proved useful in evaluating brain position 
but provided little additional information (Figure 3). Chemi- 
cally different components were easily recognized and differ- 
entiated by false color MR imaging which enhanced contrast 
(Figure 4). In this analysis, the skull content ranges in con- 
trast from light gray to dark gray. A high MR signal intensity 
is represented by light gray and low by dark gray. Living 
tissue yields a high signal intensity from soft tissue like fat 
and a lower signal intensity from dense connective tissue. 
When the brains were later sectioned, the dark gray region 
proved to be peat, whereas the light gray region was clearly 
brain matter (Figure 5). 



64 • W.W. Hauswirth, CD. Dickel, G.H. Doran, P.J. Laipis, and D.N. Dickel 



Gross examination of the brain masses after removal from 
the skull disclosed the external gyral pattern of an atrophic 
human brain shrunken to approximately 'A the original size. 
No meningeal coverings or blood vessels remained. The 
brain was tan-gray and had a soft, granular consistency. The 
two cerebral hemispheres, divided by the longitudinal fis- 
sure, were identifiable, and the Sylvian fissure was visible on 
either one or both hemispheres. Cerebellar tissue containing 
visible folia was present below the occipital lobes. The re- 
gion of the brain stem in all cases was amorphous and finer 




Figure 4. Magnetic resonance image, 1 cm thick, of medial 
portion of adult male brain 57-300, sagittal section, speci- 
men facing right. Skull removed and brain embedded in agar 
(uniform medium gray). Brain material is light gray. Several 
gross anatomical features are identifiable: A. occipital pole; 
B. frontal pole; C, lateral ventricle; D. cingulate gyrus. Im- 
ages produced by a Technical Teslacon 0. 15T resistive mag- 
net unit. Machine and pulsing techniques u.sed in routine 
clinical practice. 



structure could not be identified. Transverse slices of the 
remaining material exposed parietal, temporal, and occipital 
lobes with peat filling all fissures. Additionally, internal 
structures such as the thalamus, basal ganglia, and ventricu- 
lar system were clearly visible (Figure 5). The overall im- 
pression was that although shrunken and altered in consisten- 
cy, gross anatomical features were present. 

A more detailed analysis of tissue structure was conducted 
by light microscopy. Representative samples taken from the 
cerebral hemisphere, cerebellum, and brain stem of both 
brains were processed for light microscopy. Sections were 
stained with silver axon stain (Seiver-Munger), hematoxylin 
and eosin (H&E) for nuclei, and luxol fast blue (LFB) for 
myelin (Luna 1968). The silver-stained, H&E, and LFB sec- 
tions resembled cerebral cortex and contained yellow granu- 
lar pigment, often in pyramidal shapes, corresponding to the 
remains of neurons (Figure 6A). The cyto-architectural pat- 
tern was similar to that of fresh cerebral cortex tissue. Occa- 
sional processes consisting of parallel, arrayed fibers extend- 
ing to the cortical surface, as well as horizontal, arrayed 
fibers within the subcortical white matter, were present. No 
material staining as nucleic acid could be identified, although 
clear areas the size and shape of nuclei were apparent within 
the granular pigment (Figure 6B). Sections of cerebellum 
contained preserved Purkinje cells arranged in the spatial 
pattern seen in contemporary cerebellar tissue (Figure 6B). A 
section of the pons contained the typical pattern of crossing 
pontocerebellar tracts as well as cortical spinal tracts divided 
by remains of pontine nuclei (Figure 6C). Cellular processes 
in all sections were negative for silver stain but showed mod- 
erate staining throughout with myelin stains. 

No connective tissue elements were identified with Mas- 
son trichrome staining for collagen. Immunoperoxidase 
staining for glial fibrillary acid protein (GFAP) and S-lOO 
protein was also negative. 




Figure 5. Coronal section through agarose gel-embedded ancient brain of male 57-55 (right), and a similar section 
of a contemporary brain (left). Although the old brain section is surrounded by peat and has undergone some 
fragmentation, many gross anatomical structures are present. Two cerebral hemispheres and their gyral patterns 
clearly visible. /4, interhemispheric fissure; fl, corpus callosum;C. lateral ventricle; D. insular cortex; £, putamen; 
F. internal capsule; C, thalamus; H. third ventricle. A subtle distinction between grey and white matter is still 
apparent. 

Zagreb Pateopathotogy Symp. 1988 



Analysis of 8000-year-old brain tissue from the Windover site * 65 



''I 


^^^^B^Bt^^DI^^^^^^^H^^^KB/ . 


Ivy 






B 



1 

M 

J 




M 
J 

— « 
P 

I 

i 






»^ia 



■^;e^/ 



Figure 6: Histological comparison of contemporary brain (left) with ancient female brain (ri^ht). A. Sections of cerebral cortex 
visualized with silver axon stain (Luna, 1968). Surface of each brain at top. Small amount of peat visible on surface of ancient 
brain. Division between gray and white matter indicated on ancient brain section. At same magnification, section of modem 
brain shows only gray matter, due to general tissue shrinkage suffered by ancient brain. Vertical axonal fibers visible in gray 
matter of both sections. Small darkly staining particles in ancient brain probably represent remains of neurones. (Seiver-Munger 
stain, X 100). B. Sections of cerebellum stained with hematoxylin and eosin (Luna 1968). Correlation of contemporary and 
ancient molecular layers (A/). Purkinjc cell layers (P). and inner granular layers (1) indicated on right. Clear areas in center of 
most Purkinje cells in ancient cerebellum are probably residual nuclei (contemporary section, x250; ancient section, x4(K)). 
C. Section of pons stained with Luxol fast blue for myelin (Luna 1968). Cross-sectional views of cortical spinal tracts and 
longitudinal sections of pontocerebellar tracts clearly evident in both (contemporary section, x 100; ancient section, x2(X)). 

Zagrtb Paleopathology Symp. 1988 



66 • W.W. Hauswirth, CD. Dickel, G.H. Doran, P.J. Laipis, and D.N. Dickel 



B 




\ 




Figure 1. A. Scanning electron micro- 
graph of cerebral cortex. Remains of 
neuropil made up of intermingling tu- 
bular processes can be seen. Occasion- 
al structures representing neuronal re- 
mains can be identified at lower left. 
Bar = 5 ^.m. B. Electron micrograph of 
pyramidal neuron of cerebral cortex. 
Cell shape can be inferred from in- 
cluded lipofuscin granules (Luna 
1968). These electron dense granules 
show characteristic peripheral vacuole 
(inset). Remainder of cell shows finely 
granular, moderately electron dense 
material with a clear region in center 
(also seen by light microscopy), which 
may represent nucleus (Luna 1968). 
Two circular profiles at upper right rep- 
resent remains of neuritic processes. 
(xSOOO, inset x 22,000). 



Scanning electron microscopy revealed a background of 
processes and presumptive neurons observable as accumula- 
tions of granular structures with an outer membranelike 
covering (Figure 7 A). Transmission electron microscopy in- 
dicated the processes have a pattern reminiscent of myeli- 
nated structures; however, myelin lamellae were not identi- 
fied. No organelles associated with neurons or their 
processes were present. The most striking finding was an 
accumulation of electron dense bodies which corresponded 
to the yellow, granular pigment seen by light microscopy 
(Figure 7B). These granules resemble lipofuscin pigment 
(Tauboldetal. 1975; Adams and Lee 1982:234-237). Consi- 
stent with this interpretation was the finding of more pigment 
in the older brain (female) than in the younger brain (male). 



ISOLATION AND DEMONSTRATION OF HUMAN DNA 

Nucleic acids were extracted and purified from 15g of rela- 
tively peat-free cortex by solubilizing, chloroform-phenol 
extracting, and centrifuging in a CsCl-ethidium bromide 
density gradient. Material banding at a density of 1 .55 g/cc 
was collected and identified as DNA by DNase sensitivity 
and RNase resistance. High molecular weight DNA of 8-20 
kilobases was clearly present in an ethidium bromide stained 
gel of this DNA (Figure 8. left). 

To determine whether this DNA was of human origin, a gel 
was blotted and hybridized to a probe specific for human 
mitochondrial DNA (miDNA) (Chang and Clayton 1985), 
The probe hybridized to appropriate sized species in un- 
digested brain DNA demonstrating that human mtDNA was 
present (Figure 8, right). To confirm the presence of human 
DNA a dot blot of 80()()-ycar-old DNA was probed with an 
Alu repeat sequence (Figure 8, right). The Alu sequence 



hybridized to old human DNA but not to a peat sample from 
the same level. The experiment was repeated several times 
using DNA samples from different old brains with similar 
results. 

The total yield of DNA was about 1 ^.g/g tissue, or 1% of 
that normally isolated from fresh tissue. Also, the amount of 
mtDNA present in the old DNA sample appears low relative 
to total isolated DNA. A comparison of hybridization sug- 
gests that about 0.05% of the total old DNA was mtDNA; 
DNA isolated from fresh brain tissue yields 0.5%- 1% 
mtDNA. Quantitation of Alu sequences on dot blots allowed 
an independent estimate of the fraction of human DNA se- 
quences in the old DNA samples (data not shown). We esti- 
mated that Alu sequences were present at 1% of the level of 
that from an equivalent amount of human placental DNA. 
The low yield of human mtDNA sequences could have sever- 
al potential causes: preferential loss of mitochondrial se- 
quences may occur during extraction; preferential degrada- 
tion of mitochondrial sequences may occur during 8000 
years or during the immediate postmortem period; and signif- 
icant amounts of nucleic acids from the surrounding plant 
material may be present in the old-brain cortex sample. If the 
latter situation is the case, the apparent fraction of any specif- 
ic human sequences would be diluted by plant DNA se- 
quences. Although the surrounding peat does contain about 
the same amount (on a per weight basis) of DNA as brain 
tissue, this DNA does not hybridize to the human mtDNA 
probe (Figure 9). 

When the mtDNA was digested with Eco R I , the expected 
(Anderson et al. 1981) 8kb fragment which should appear 
after hybridization with the probe was not present (Figure 8, 
right). However, partial conversion of open-circular to linear 
molecules did take place, as would be expected if only a 
fraction of the Eco Rl recognition sequences were present. 

Ztign'h PaleopalhoUffty Symp. 198fi 



Analysis of 8000-year-old brain tissue from the Windover site • 67 




A B C D 




Figure 8. Identification of human mtDNA sequences in DNA troni 8UUU-year-old adult male brain. Total DNA 
isolated and purified as described in text. An aliquot was digested with EcoRI and electrophoresed on a 1 % agarose gel 
along with an undigested aliquot and samples of authentic human KB cell mtDNA treated similarly. After staining and 
photography, gel was blotted and hybridized to a human mtDNA-specific probe (Chang and Clayton 1985), washed and 
autoradiographed. Central lanes containing enzymes, buffers, and carrier tRNA used in extraction, and enzyme 
digestion showed no hybridization to probe. Lane A, undigested KB cell mtDNA; lane B, EcoRI-digested KB cell 
mtDNA; lane C. undigested ancient DNA; lane D. EcoRl-digested ancient DNA. OC, L. and EcoRl refer to positions 
of open- (nicked) circular, linear, and 8050-base pair (bp) EcoRI (D-loop-containing) fragment of KB cell mtDNA, 
respectively (Anderson etal., 1981; Houcket al., 1979). Left: Ethidium-stainedgel. /?/g/ir.Autoradiograph of blotted 
gel. Lanes A and B were exposed for 3 days, lanes C and D for 7 days. 



Resistance to enzyme digestion is an intrinsic property of the 
old DNA because a bacterial plasmid DNA mixed with this 
DNA sample did digest to completion under the same condi- 
tions. The inability to completely digest the DNA may be due 
to base modification leading to a loss of restriction endo- 
nuclease site recognition. 

The old DNA lacked supercoiled, covalently closed cir- 
cles (Figure 8, right). The reason for the absence of super- 
coiled molecules has not been investigated further at present, 
but many spontaneous processes can lead to single-strand 
nicks in DNA, converting covalently closed molecules to 
open-circular forms (Vinograd et al. 1965). Multiple single- 
stranded nicks or damage resulting in a double-stranded scis- 
sion would lead to linear, full-length molecules, as was seen. 

High molecular weight and a surprisingly high fraction of 
intact open-circular mtDNA was observed in these DNA 
samples (Figure 8). Both of these observations may be due to 
DNA damage caused by depurination leading to intcrstrand- 
crosslinking of DNA (Goftln et al. 1984). Crosslinking 
would raise the apparent double-stranded molecular weight 
of the DNA, greatly increase the lifetime of circular DNA 
forms, interfere with restriction digestions, and perhaps also 
interfere with DNA hybridization experiments by preventing 
strand separation. This type of damage has been shown to be 
enhanced in aqueous solution (Goffin et al. 1984). 

The presence and condition of nuclear DNA was also in- 
vestigated. Restriction endonuclease-digested DNA was 

Zagreb Paleopathology Symp. J9H8 



probed with radiolabeled nuclear DNA and RNA sequences 
present as multiple copies in the human genome (an Alu 
sequence, a large and small ribosomal RNA) (Houck et al. 
1979; Long and Dawid 1980). None of these probes 
hybridized to restriction fragments of a defined size (data not 
shown). If nuclear DNA was damaged in a similar manner as 
mtDNA and largely resistant to restriction endonuclease di- 
gestion, discrete restriction fragment bands of multicopy or 
single copy genes would not occur in hybridization experi- 
ments. In contrast, mtDNA occurs as a small 16 kb circular 
molecule and migrates as a discrete species without depend- 
ing upon recognition of specific undamaged sequences by 
restriction endonuclease; therefore, it can be detected in hy- 
bridization experiments. Alkaline cleavage of the 8000-year- 
old DNA also reveals a significant amount of DNA damage 
(data not shown). It is estimated that these alkali-sensitive 
sites, many of which may represent apurinic nucleotides, are 
present at the 1% level. 

An attempt was made to clone and compare DNA se- 
quences from several brains with nucleotide sequences of 
genes or other DNA sequences already known. Thus far, old 
brain nucleotide sequences have not corresponded to any 
known DNA sequence. A small library of DNA fragments 
was constructed using a partial Alu I digest and an M13 
cloning vector. Approximately 1000 clones containing small 
inserts (50-1000 bp) were isolated and 90 were screened for 
homology to human mtDNA, human Alu rep)eat sequences. 



68 • W.W. Hauswirth, CD. Dickel, G.H. Doran, P.J. Laipis, and D.N. Dickel 



A B C D E 



Table 4. sites where brain li^ucs have been found 



Locations 



Dales 




Condition^ Reference 



Figure 9. DNA dot blot comparing amount of human Alu 
sequences (plus pBR322 plasmid DNA) in 8000-year-old 
DNA, nearby peat DNA, and contemporary human DNA. 
Cloned Alu sequence (in pBR322) was nick translated and 
hybridized to dot blot containing: lanes A and B, pBR322 
DNA 100ng(B-l)to0.2ng(A-5);/a/it'C, lOOngofhuman 
placental DNA; lane D, 10 |i.g of 8000-year-old DNA from 
Skull #57-77; lane E. 10 jjig of 8000-year-old DNA from 
peat near bone deposits. Rows 2 to 5 contain serial 2-fold 
dilutions of sample in row 1 . 



or human ribosomal genes. The inserts from three clones 
exhibiting weakly positive hybridization signals were se- 
quenced. None showed significant (> 70%) homology to 
any of the three classes of target genes nor did these inserts 
(392 bp total) possess homology to any known DNA se- 
quence by computer analysis of the Genetic Sequence Data 
Bank maintained by the NIH. This may not be surprising 
since only a small fraction (< 1 %) of the human genome has 
been sequenced. 

An alternative approach to demonstrating the potential 
human origin of some cloned fragments involved hybridizing 
Southern blots of modem human brain DNA with probes 
made from the cloned Alu inserts described above. Twelve 
randomly selected probes were made and hybridized. In two 
instances di.screte bands of modern human DNA hybridized 
suggesting that at least a portion of the old brain DNA is of 
human origin. Again, the precise identity of the sequences 
remains obscure. 

Discussion 

The Windover site yielded preserved brain tissue of human 
origin dating to the Early Archaic period. It is the oldest 
human soft tissue yet analyzed at a molecular level. An inter- 
disciplinary approach demonstrated the presence of human 



Fori Si. Marks, FL 


1818-1819 AD. 




Dailey cl al. 1972 


Kagamill Island, AK 


1740 A.D. 




Zimmerman el al. 1971 


Denmark 


1236-1540 A.D. 




Tkoc2 el al. 1979 


Chihuahua, Mexico 


1040-1260 AD. 




Luibel-Hulen 1985 


Denmark (Grauballe Man) 


210-410 A.D. 




Glob 1%9 


Lindow Moss, England 


211 +80 A.D. 




Stead and Turner 1985 


Droitwich, England 


200 A.D. 




Oakley 1960 


HoUand (Windeby Girl) 


100 A.D. 




Glob 1969 


Egypl (PUMIV) 


100 B.C. -100 A.D. 




Reyman and Peck 1980 


Denmark (Tolland Man) 


210 B.C. +40 




Glob 1969; Fischer 1980 


Egypl (#1981/575) 


332 - 30 B.C. 




David and Tapp 1984 


Borremosse, Denmark 


430 B.C. 1 100 




Glob 1%9 


Borremosse, Denmark 


650 B.C. +80 




Glob 1969 


Egypt (POM III) 


835 B.C. 




Riddle 1980 


Egypt (PUM III) 


835 B.C. 




Reyman and Peck 1980 


Egypt (ROM 1) 


1000 B.C. 




Millet et al. 1980 


Egypl (Tetisheri) 


1600- 1570 B.C. 




Harris and Weeks 1973 


Egypl (Salford head) 


- 




David and Tapp 1984 


Egypl (#22940) 


- 




David and Tapp 1984 


Egypt 


3000 B.C. -600 A.D. 


L 2 


Smith 1902 


Peru 


- 




Allison and Ckrszten 1982 


Bay West, FL 


6400-6900 B.P. 




Beriaull cl al. 1981 


Little Salt Spring, FL 


8000 B.P. 




Clausen et al. 1979 


Windover. FL 


SOW B.P. 


4 


Doran et al. 1986 


Warm Mineral Springs, FL 


10000 B.P. (esl.) 


4 


Royal and Clark 1960 



a. L artificial mummy; 2, natural mummy; 3, peat bog; 4, damp or water-saturatei 
environment 

DNA as well as remnant cellular and anatomical structure. 
These observations raise questions in two broad categories: 
first, what factors resulted in the preservation at Windover 
and second, what type of information does the presence of 
ancient DNA make available to anthropology, molecular bi- 
ology, and other disciplines? 

Examples of human soft tissue preservation are prevalent 
but discovery of preserved brain material at first appeared 
unique, since the brain can undergo rapid autolysis (self- 
disintegration of cellular components) (Becker and Barron 
1961). However, brain material may remain as a recogniz- 
able mass after all other soft tissue has disappeared (Bass 
1984) and several instances of preserved brain material in an 
archeological setting have been reported (Table 4). Soft 
tissue preservation can occur in a variety of environments 
ranging from water-saturated to extremely dry or cold. In- 
stances of preserved human tissue as old as the Windover 
material are less common. Most examples of human soft 
tissue preservation are from hot, dry environments. Some of 
these have been subjected to elaborate postmortem treatment 
(Allison 1985; Peck 1980; Pretty and Calder 1980). Egyptian 
mummies (2686 B.C. to a.d. 641) are the best known exam- 
ples of complex postmortem treatment. The postmortem pro- 
cess generally involved dehydrating the body chemically 
with dry natron, a naturally occurring mixture of Na^CO,, 
NaHCO,, and NaCl or Na2S04 and then coating the body 
with resins (Harris and Weeks 1973:8 1-92; Tapp 1984;Peck 
1980). 



Zagreb Paleopathology Symp. 1988 



Analysis of 8000-year-old brain tissue from the Windover site • 69 



Bodies, however, can also be preserved in hot, dry en- 
vironments through accidental or intentional exploitation of 
natural desiccation. In these instances, the climate must be 
dry enough that dehydration of the bodies is rapid. Further- 
more, dry conditions must persist up to the time of discovery. 
Examples of this type of preservation are found in predynas- 
tic Egypt (before 2686 B.C.) (Smith 1902), Peru (Vrceland 
and Cockbum 1980), the American Southwest (El-Najjarand 
Mulinski 1980), Australia (Pretty and Calder 1980)and other 
areas (Ascenzi et al. 1980). 

Other mummified or frozen remains have been found in 
cold environments ranging from the high-altitude desert en- 
vironments of Peru and northern Asia to the arctic areas of 
Alaska and Greenland (Artamonov 1965; Zimmerman and 
Smith 1975; Hansen et al. 1985; Dekin 1987). Under these 
conditions dehydration may have taken place by sublimation 
of body moisture (Vreeland and Cockbum 1980). The bone 
and soft tissue in these samples are frequently in an excellent 
state of preservation (Vreeland and Cockbum 1980; Hansen 
etal. 1985). 

A variety of aqueous environments have yielded preserved 
tissue. The highly acidic (pH < 4) peat bogs of northern 
Europe have produced human remains with a remarkable 
amount of tissue preservation (Glob 1969; Fischer 1980). 
Skin and hair are intact (essentially tanned), intemal organ 
preservation is less predictable, and bone is usually highly 
demineralized; less acidic conditions yield better preserved 
bone (Glob 1969). 

Ancient human remains from damp environments or non- 
acidic, water-saturated environments like Windover are 
rarer, but have occurred. Human skulls containing the appar- 
ent remnants of brain tissue were found earlier at several 
Florida sites (Royal and Clark 1960; Dailey et al. 1972; 
Clausen etal. 1979; Beriault etal. 1981). A Danish medieval 
cemetery yielded 56 of 74 skulls with brain material; like the 
Windover site no other soft tissue was preserved (Tkocz et al . 
1979). Most of the bog bodies of northern Europe are from 
acidic environments but some are found under less acidic 
conditions (pH 5-7.5), and in these cases the body is found 
as skeleton or adipocere (Fischer 1980). 

Upon comparing descriptions of preserved tissue found at 
other archeological or forensic sites with the material found 
at Windover, we note that specimens and locations most 
similar to Windover came from sites where adipocere forma- 
tion occurred. AdiptKcre (also known as "grave wax") is a 
mixture of free fatty acids, primarily palmitic acid, and soaps 
resulting from the postmortem hydrolysis and hydrogenation 
of fats present in naturally occurring fat tissue in the body 
(Mant 1957;Zivanovic 1982:18-19). Damp conditions, fat- 
ty tissue, electrolytes (which may come from body fluids), 
and some putrification (to initiate hydrolysis) must be present 
for adipocere formation to occur (Mant 1957). Apparently at 
Windover, burial practices and physical and chemical condi- 
tions allowed putrification to begin but the process was 



halted before complete decomposition of brain tissue oc- 
curred. 

The conditions at Windover that appear most likely to 
enhance tissue preservation by inhibiting bacterial growth 
are the high sulfur levels in water and peat, the high amounts 
of minerals present in the water, and the anaerobic conditions 
which begin 30 cm below the peat surface. DNA within the 
tissue was preserved owing to at least two other factors: first, 
waterat Windover is nearly neutral (pH 5.3-6.8), particular- 
ly in the red-brown peat stratum; second, the anaerobic prop- 
erty of the water limits oxidative DNA damage. Thus, DNA 
alteration due to acid depurination. deamination. and oxida- 
tion was minimized. Interestingly, a low temperature may 
not have been a factor in DNA preservation since modem 
subsurface ground water temperatures are around 23°C. Al- 
though DNA has been isolated from tissues preserved 
through rapid drying (Paabo 1985; Higuchi et al. 1984; 
Rogers and Bendich 1985; Johnson et al. 1985), the present 
results show that tissues recovered from water-saturated en- 
vironments under conditions of anaerobia, neutral pH, and 
high ion levels also yield preserved DNA. 

In an archeological setting, DNA survival not only in- 
cludes chemical factors but also ethnological practices that 
may act to influence burial conditions and, thus, rate of tissue 
decomposition and DNA survival. Individual differences in 
tissue integrity may reflect variations in either burial environ- 
ment or the interval and conditions which prevailed between 
death and interment, or both. Windover skeletal material 
buried along the deeper edge of the pond was well preserved, 
but was disarticulated and appears to have been slowly trans- 
ported down slope. Burials in the more shallow edge of the 
pond, found in the third and final field season, were articu- 
lated but poorly preserved. There is no indication of second- 
ary burial at Windover, although the practice was widespread 
in later New World populations (Ubelaker 1974; O'Shea 
1984; Churcher and Kenyon I960). The interment pattcm 
resembles Floridian aquatic burial practices occurring both 
earlier and later than the Windover site, possibly reflecting a 
long-term or recurring religious theme in Florida (Royal and 
Clark I960; Clausen etal. 1975; Beriault et al. 1981; Whar- 
ton etal. 1981; Sears 1982). It is clear that rapid interment is a 
necessary factor in tissue preservation in environments pro- 
moting rapid decomposition. Preservation may also reflect 
sex- and age-specific burial patterns. However, at Windover, 
brain material has been recovered from infants, adolescents, 
young and older adults representing both sexes, thus indicat- 
ing little status distinction in burial pattems. Agreement be- 
tween the ages of the peat surrounding the skeletal material 
and the bone itself also suggests primary burials in shallow 
graves. There are some indications that the bodies may have 
been deposited in water deep enough to require pointed "hold 
down" stakes and stakes of unmodified wood. We suggest, 
therefore, that in temperate latitudes of the New World, 
rapid, simple burial practices in an anaerobic, water- 



Zagrrb Puleopalhology Symp. 1988 



70 • W.W. Hauswirth, CD. Dickel, G.H. Doran, P.J. Laipis, and D.N. Dickel 



saturated matrix may be an important factor in soft tissue and 
DNA preservation. 

Nucleic acids (especially mtDNA) recovered from pre- 
historic populations could prove enormously useful in an- 
thropological studies of population genetics. Several re- 
searchers maintain reservations about the reliability of 
mtDNA for cladistic studies (branching relationships) ( Jones 
and Rouhani 1986; Slatkin 1987; Vawter and Brown 1986; 
Wainscoat 1987; Wainscoat et al. 1986). However, several 
teams have suggested that restriction maps of mtDNA may 
be useful for the study of cladistic relationships, timing of 
divergence, and investigations of multiple vs. single origins 
of populations. The characteristics that make mtDNA studies 
attractive are its high mutation rate (estimated 10 times that 
of nuclear DNA) (Cann et al. 1984; Cann and Wilson 1983; 
Wainscoat 1987) and its uniparental and haploid pattern of 
inheritance (Cann etal. 1987;Greenbergetal. I983;Johnson 
etal. 1 983 :Whittam etal. 1986; Wilson etal. 1985). Several 
pilot studies have used mtDNA data to investigate the place 
and timing of the origin of modem Homo sapiens sapiens 
(Cann etal. 1987; Denaro etal. 1981;Greenberget al. 1983; 
Johnson et al. 1983). Other anthropological studies have in- 
vestigated southwestern United States Amerind and Asian 
diversity and relationships (Wallace et al. 1985) and genetic 
homogeneity of woridwide Jewish populations (Meyers 
1985). 

While there is reason for caution in the interpretation of 
mtDNA data (e.g., see Wainscoat 1987), there is little doubt 
that prehistoric mtDNA from ancient Amerind and other 
populations would be an extraordinary find if intact enough 
for investigating gene flow, bottle necks and population di- 
vergence. Although it remains uncertain whether the Win- 
dover material will provide the preservation needed for these 
types of studies, the preservation of mtDNA in this soft tissue 
suggests mtDNA may also be found in tissues from other 
archeological sites. 



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dictable. 



Zagreb Paleopathology Symp 1988 



Diagnosis of thalassemia in ancient bones: 
Problems and prospects in pathology 

Antonio Ascenzi, A. Bellelli, M. Brunori, G. Citro, R. Ippoliti, 
E. Lendaro, and R. Zito 



Porotic hyperostosis" is a generic term applied to a type of 
bone lesion characterized by a symmetrically distributed in- 
crease in the volume of the skeleton, associated with a reduc- 
tion of the bone texture. Such a type of lesion was recognized 
for the first time by Cooley and Lee (1925) as a feature 
peculiar to thalassemia. Subsequent investigations (Moseley 
1963; Ascenzi 1976.1979) deeply modified the original 
view, so that nowadays it is quite obvious that porotic hyper- 
ostosis can be induced by any disease that leads to an increase 
in bone marrow volume, causing the skeleton to adapt its 
capacity to contain the excess of hemopoietic marrow. The 
most profound changes of porotic hyperostosis are seen in 
children, and they diminish as the individual approaches 
adult life (Caffey 1951). This agrees with Neumann's law in 
which half of the bone marrow is adipose in the adult, while 
the entire long bone marrow is hemopoietic in the child. 
Because of this, the adult can double the volume of hemo- 
poietic marrow without any change to the skeleton; on the 
other hand, even a limited hyperplasia of the hemopoietic 
marrow induces in the subadult a volumetric increase in the 
bone marrow. A list of conditions inducing porotic hyper- 
ostosis has been compiled by Moseley (1965). and the sub- 
ject has been reviewed by Ascenzi (1976,1979). In theory, 
any condition that abnormally increases the rate of blood cell 
turnover can produce porotic hyperostosis. Disea.ses known 
to do this include: congenital hemolytic anemias (thalasse- 
mia, sickle cell disease, hereditary spherocytosis, hereditary 
elliptocytosis. hereditary nonspherocytic hemolytic anemia), 
iron deficiency anemia, cyanotic congenital heart disease, 
polycythemia vera in childhood. 

From what is reported above it may be inferred that, in 
paleopathologic terms, porotic hyperostosis is the only suita- 
ble evidence for the existence of medullary hyperplasia, ei- 
ther primary or secondary, when the skeleton is the only 
tissue which time has preserved. However, skeletal remains 
showing porotic hyperostosis have been unable so far to pro- 
vide unequivocal information on the specific disca.se syn- 
drome which led to bone lesions. 

Zagreb PaUopathotogy Symp. 1988 



Starting with these premises, we attempted to remove am- 
biguities for the diagnosis of thalassemia in skeletal remains 
by examining the possibility that hemoglobin arising from 
postmortem lysis of the erythrocytes may remain adsorbed to 
the bone and be specifically detected. In a previous paper 
(Ascenzi et al. 1985) we provided evidence that hemoglobin 
is indeed measurable in skeletal remains dating back to En- 
eolytic age using an immunochemical technique. This dis- 
covery encouraged further investigations, and in this paper 
we present additional progress toward an unequivocal diag- 
nosis of thalassemia in skeletal remains with porotic hyper- 
ostosis. 

Materials and methods 

Samples (lumbar vertebrae, skulls and other bones) were 
obtained from the Verano cemetery of Rome (samples buried 
for 15 to 30 years), from the S. Senatore Catacumbae in 
Albano Laziale, Rome (samples dating back from the first to 
thirdcentury of thisera), from the Necropolis of Porto (Isola 
Sacra, Rome, second century B.C.) and of Castiglione 
(Rome, 1000 B.C.). 

Bones were frozen in liquid nitrogen and crushed into 
powder with a hydraulic press. The powder was extracted 
with 6M urea for 4 hours at room temperature and neutral pH . 
The extract was filtered and urea was removed by means of 
gel permeation chromatography on Sephadex G25 (Phar- 
macia, Sweden). 

Antiserum against human apohemoglobin (globin) was 
raised in adult male rabbits with three subcutaneous inocula- 
tions of 0.8 mg of the antigen in complete Freund adjuvant. 
Hemoglobin constituent alpha and beta chains were prepared 
as by Bucci and Fronticelli (1965) and antisera against the 
two purified chains were obtained following the same pro- 
cedure. The content of hemoglobin remnants in bone extracts 
was determined with the immunoblot technique employing a 
Bio Dot apparatus (BioRad, U.S.A.); solutions of apo- 
hemoglobin, alpha and beta chains were employed as stan- 

73 



74 • A. Ascenzi, A. Bellelli, M. Brunori, G. Citro, R. Ippoliti, E. Lendaro, and R. Zito 



% I 




lUO 200 

Antigen (ng) 



300 



Figure 1 . Reaction of antiglobin rabbit antiserum against 
liuman alpha and beta chains. 



dards. Quantification was achieved by integration of dot in- 
tensity using a LKB Laser Scanner densitometer and digital 
integration. 

Results 

Apohemoglobin (globin), alpha chains and beta chains were 
used to standardize rabbit antisera raised against human 
globin. The results of one experiment illustrating this pro- 
cedure are shown in Figure 1 . 

Lumbar vertebrae extracts were tested with the same anti- 
serum and the content of hemoglobin in the skeletal remains 
estimated by comparison with the standard curves. As al- 
ready shown qualitatively (Ascenzi et al. 1985), hemoglobin 
or hemoglobin fragments can be determined quantitatively in 
bone extracts with this technique. The average hemoglobin 
content of lumbar vertebrae from adults buried for 1 5 years is 
0.7 to 1 fig/ 100 gram of dry powder (Table 1 ). 

A larger amount of titratable material is extracted from the 
lumbar vertebrae of younger individuals. As a general rule, 
the younger the individual, the higher the hemoglobin con- 
tent of the bone extracts, as may have been anticipated. 

Skull and other bones were used to determine the correla- 
tion between hemoglobin content and anatomy and physiol- 
ogy of the skeleton. It was found that, for the same individu- 
al, the absolute amount of hemoglobin detected from bone 
powder varies markedly with the type of bone examined. 
Highly vascularized bones, whose marrow exhibits high 
erythropoietic activity, are (as expected) much richer in titra- 
table hemoglobin than bones with low or absent erythropoie- 
tic activity. Data in Table 1 report one example by comparing 
the hemoglobin content of the lumbar vertebrae and the skull 
of an infant. 



Table L Content of hemoglobin (or hemoglobin 
fragments) in lumbar vertebrae extracts (except D2 = 
skull); quantitation with antiglobin rabbit antiserum 

Sample Age of Time elapsed Hb ng/lOO g bone 
subject pom death () = No. of tests 

A senescent 15 years 0.16-0.2 (3) 

B adult 15 years 0.9-1.0(3) 

C adult 15 years 0.7-1.0(3) 

Dl infant 15 years 1.1-1.6(3) 

D2 infant 15 years 0.2-0.4 (3) 



Table 2. Content of hemoglobin (or 
hemoglobin fragments) in lumbar vertebrae 
of adults at different times after death (in 
years) 

Sample Time elapsed Hb iig/100 g bone 
from death () = No. of tests 



A 


15 years 


0.7 -LO (3) 


B 


15 years 


0.9 -LO (3) 


C 


30 years 


0.6-1.0(3) 


D 


2000 years 


0.6-0.9 (3) 



These results are in complete agreement with the known 
correlation between the age of the subject and erythropoietic 
activity, since in very young individuals all the skeleton 
houses active marrow. Surprisingly, the amount of hemo- 
globin detected in lumbar vertebrae of adults seems to be 
essentially independent of the time elapsed from burial, at 
least for the homogeneous set of data reported in Table 2. 
Because very ancient samples are rare and some bones are 
more easily destroyed, the oldest specimens consisted only 
of lumbar vertebrae and skulls; nevertheless similar depen- 
dence of hemoglobin content on age at death and anatomy 
was demonstrated (data not shown). 

The reactivity of antialpha and antibeta rabbit antisera was 
standardized as described above, and the content of alpha 
chains in bone extracts was determined. Due to some residual 
cross-reactivity, only a semiquantitative estimate is reported; 
however, it was clearly observed that both chains can be 
detected in ancient skeletal remains, and are present in signif- 
icant amount. 

This is particularly important in the case of the alpha 
chains, in view of the known sensitivity of these polypeptides 
to proteolytic degradation (Chalevelakis et al. 1975), which 
had raised concern that it might be difficult to determine 
quantitatively the content of each chain in ancient skeletal 
specimens. 

Za^rfh /'{ilfoptilholo^y Syrnp. IVftft 



Diagnosis of thalassemia in ancient bones • 75 



Discussion 



Literature cited 



The results described above demonstrate that the immu- 
nochemical technique employed in this work is sufficiently 
sensitive and reliable to allow quantitative titration of hemo- 
globin and its constituent polypeptide chains in bone ex- 
tracts, even some thousands of years after burial of the indi- 
vidual. It is important that, as expected, the results indicate 
that bones with higher erythropoietic activity contain greater 
amounts of titratable hemoglobin or hemoglobin fragments 
than those characterized by reduced erythropoiesis. More- 
over it is clear from data in Table 2 that, within the accuracy 
of the methodology, no significant decrease of hemoglobin 
content is observed with the archeological age of the speci- 
men, within a range of 15-2000 years. Previous results ( As- 
cenzi et al. 1985) indicated a loss of immunochemically 
titratable hemoglobin with time of burial, but it may be that 
characteristics of the soil, humidity, or other interferences 
may be more important than age after death in determining 
the final content of detectable protein. It should moreover be 
emphasized that some uncertainties about the quantitative 
estimate of hemoglobin in bone extracts remain, owing to 
the interferences by false positive immunochemical reac- 
tions. 

As an example, it may be mentioned that two samples of 
lumbar vertebrae of adult humans from different burial sites 
(both approximately 2000 years old) were tested against an 
affmity chromatography purified antialpha chain Ig fraction 
of the rabbit antiserum as well as against the antialpha de- 
pleted fraction of the same serum. The hemoglobin content in 
the two tests was comparable (1-3 |xg/IOO g), while the 
nonhemoglobin reactivity was zero in one specimen and 
almost eight times higher than that of hemoglobin in the 
other. 

Up to now. the immunochemical technique has been ap- 
plied only to morphologically normal bones, but it may be 
possible to determine the content of hemoglobin remnants 
even in bones whose morphology indicates hyperactive 
erythropoiesis. As reported above, differential diagnosis of 
chronic anemias with increased but insufficient compensa- 
tory erythropoiesis is usually impossible on the mere anatom- 
ical evidence of porotic hyperostosis. In this respect, the 
immunochemical technique employed here represents a pos- 
sible tool for an unequivocal diagnosis of alpha and beta 
thalassemias (and possibly other hemoglobinopathies) in 
very old skeletal remains. Further work along these lines is in 
progress. 



Asccnzi. A. 1976. Physiological Relationship and Pathological In- 
terferences Between Bone Tissue and Marrow. In G.H. Bourne, 
cd.. The Biodwmislry and Physiology of Bone. 403-444. New 
York; Academic Press. 

1979. A Problem in Paleopathology: The Origin of Thalas- 
semia in Italy. Virchows Archiv A Pathological Anatomy and 
Histology. 384:121-130. 

Ascenzi, A.. M. Brunori. G. Cilro. and R. Zito. 1985. Immu- 
nological Detection of Hemoglobin in Bones of Ancient Roman 
Times and of Iron and Eneolithic Ages. Proceedings oj the Na- 
tional Academy of Sciences. 82:7170-7172. 

Bucci, E., andC. Frontieelli. 1965. A New Method for the Prepara- 
tion of Alpha and Beta Chains of Human Hemoglobin, yourna/ of 
Biological Chemistry. 240:PC 551 . 

Caffey, J. 1951. Cooley's Erythroblastic Anemia. Some Skeletal 
Findings in Adolescent and Young Adults. American Journal of 
Roentgenology and Radium Therapy. 65:547-560. 

Chalevelakis. C, J.B. Clegg. and D.J. Weatherall. 1975. Im- 
balanced Globin Chain Synthesis in Heterozygous p-Thalas- 
semic Bone Marrow. Proceedings of the National Academy of 
Sciences. 72:3853-3857. 

Cooley, T B . . and P. Lee . 1 925 . Series of Cases of Splenomegaly in 
Children with Anemia and Peculiar Bone Changes. Transactions 
of the American Pediatric Society. 37:29-30. 

Moseley. J.E. 1963. Bone Changes in Hematologic Disorders 
(Roentgen Aspects). Orlando, Fla.: Grune and Stratton. 

1965. The Palcopathologic Riddle of '■Symmetrical Os- 
teoporosis. " American Journal of Roentgenology, Radium Thera- 
py and Nuclear Medicine, 95:135-142. 

Summary of aiidif.nce discussion: Before one can attempt to 
correlate porotic hyperostosis with the chemical findings of globin 
pattems common to thalassemia, one must develop laboratory 
methods not only for alpha and beta chains but also delta and gam- 
ma. The work presented in this study used trabecular bone becau.se 
of its hematopoietic marrow and therefore because hemoglobin was 
present there in vivo. Unfortunately during interment its porosity 
also invites diagenetic changes which might alter protein structure. 
Use of ribs as source material might minimize the diagenetic haz- 
ard. Dental pulp is even more sheltered from the environment. 
Conceivably the problem of antibodies against alpha and beta 
chains also cross-reacting with gamma chains might be prevented 
by raising antibodies in appropriate animals against an antigen com- 
posed only of a peptide, preferably one with a known amino acid 
sequence; even better would be production of a monoclonal anti- 
body in the usual manner. Considering the small quantity of protein 
present in fossil material, the use of radioimmunoassay methodol- 
ogy would appear to be desirable. 



Zagreb Patfopathotogy Symp. 1988 



Trends and perspectives in 
paleoparasitological research 



U.E.C. Confalonieri, L.F. Ferreira, A.J.G. Araujo, M. Chame, 

and B.M. Ribeiro Filho 



This report presents some methodological questions in- 
volved with our research on parasites from archeological 
material in Brazil. Our investigations deal mainly with para- 
sitological findings in human and animal coprolites from 
South American archeological sites and rarely with mum- 
mies, since, for paleoecological and paleoanthropological 
reasons, mummies are not common in Brazil. A review of 
helminths in mummified human remains has been presented 
recently (Home 1986:4-5). 

The first finding of parasites in archeological material was 
in 1910, when Ruffer found Schistosoma haematobium eggs 
in renal tissue of Egyptian mummies, and paieoparasitology 
has been growing ever since as a scientific discipline. The 
term "paieoparasitology" was first used by Jean Baer 
(1971:317), although he mentioned it only parenthetically, 
commenting on the study of the coevolution of hosts and 
parasites. It acquired its definitive meaning after the first 
paper of Ferreira et al. (1979) and is widely used today to 
characterize the study of parasitic forms in archeological 
material. After some decades of research, interesting find- 
ings have been obtained, and new questions arise concerning 
the interpretation of these findings. In this report we relate 
our experience regarding the use of some methods in pal- 
eoparasitological investigation as well as difficulties in the 
interpretation of the data. 

In a recent review, Reinhard et al. (1988) discussed the 
principal techniques for isolation of parasitic forms from 
coprolites in soil and fecal deposits from archeological sites, 
and thus these will not be commented upon here. 

In paieoparasitology as well as in paleopathology sensu 
stricto, the main methodological question is the reliability of 
the diagnosis of the material. Our experience primarily in- 
volves the study of eggs and larvae of intestinal parasitic 
helminths found in archeological material from South Amer- 
ica. These differ to some extent from those in the Old World 
material (see below). 

The methodological issues with which we deal involve 
three main aspects: ( 1 ) identification of the zoological origin 



of the material found (human or animal?); (2) recognition of 
the possible morphological alterations in the parasitic forms 
resulting from the desiccation process in archeological de- 
posits or from other physical and biological events during 
many centuries; (3) better techniques for studying parasite 
morphology, aimed toward their specific identification. 

It is necessary to stress that the approach to these questions 
is based on knowledge from zoological and morphological 
sciences, biometrics, electron microscopy, and biochemis- 
try. We will comment only on analysis of helminths, since the 
other common intestinal parasites, the protozoans, are poorly 
preserved and can rarely be found. 

The first problem faced by paleoparasitologists is the iden- 
tification of the origins of coprolite material found free in 
archeological sites, that is, outside mummified bodies. It 
must be stressed there is an important difference regarding 
the contents of parasite-containing archeological sediments 
from the New World and the Old World. Because the latter 
sites are mostly historical and urban, the possibility of mis- 
diagnosis lies between human coprolites and fecal material 
produced by domestic animals. In the American sites, at least 
those from South America, human coprolites have been 
found in places which could have been also occupied only by 
wild animals, since the South American Paleo-Indian did not 
domesticate animals. Therefore we are doing surveys at the 
archeological sites in the semi-arid regions of Brazil to in- 
crease our knowledge of the morphological aspects and con- 
tents of the feces of recent local fauna, basically the same 
animals as from the prehistoric Holocene. This approach was 
initiated by Fry (1977:7) and is being used to describe the 
size, form and contents of fresh animal feces as well as feces 
naturally and artificially desiccated. With this we intend to 
prepare a catalogue to serve as a guide for the identification 
of coprolites. So far the results are encouraging because of 
the peculiarities of South American fauna in general, particu- 
larly at Brazilian excavation sites where there are few large 
omnivorous or carnivorous animals whose feces could be 
more easily misidentified as those of human origin. 



76 



Zagreb Paleopathology Symp 1988 



Trends and perspectives in paleoparasitological research • 77 



However, for the assessment of the origin of coprolites we 
must not forget other parameters, such as their food content 
as well as parasite composition known to be typical for the 
human host. Such parameters also include biochemical stud- 
ies which, although still in their infancy, certainly became an 
important option after the identification of steroids from 
2000-year-old North American coprolites (Lin et al. 1978). 

A second problem relates to the possible structural modi- 
fications found in parasites contained in fecal material from 
archcological sites. Under the influence of environmental 
factors, parasite remains could undergo deformities and/or 
size modifications making their identification difficult or 
even impossible. Such physicochemical processes could de- 
stroy parasitic forms in the fecal mass; these phenomena 
seem to be responsible for the scarcity of findings of pro- 
tozoan cysts in coprolites. The first attempt to solve this 
problem came from the experimental approach inaugurated 
by Adamson (1976) when he assessed the persistence of eggs 
of Schistosoma sp. in artificially desiccated tissues in order to 
evaluate the actual frequency of these findings in Egyptian 
mummies. This approach was then extended to several nor- 
mal tissues as well as to soft tissue lesions (tumors, for exam- 
ple) by Zimmerman (1972,1977,1978) in an effort to assess 
the possibilities of histopathological diagnosis in mummified 
bodies. More recently we started to study the morphological 
modifications which occurred in helminth eggs and larvae 
after artificial desiccation and rehydration of fresh feces 
using different techniques. We have tested whether helminth 
eggs, such as those of the nematode genus Trichuris sp. 
(Confalonieri et al. 1985) and ancylostomids (Araujo 1987), 
whose diagnosis depends not only on qualitative mor- 
phological characteristics but also on size variations, would 
undergo significant alterations in their dimensions. 

So far these experiments have demonstrated that the desic- 
cation process does not cause deformities in these biological 
structures that would hinder an adequate identification. 

Finally, detailed morphologic study of parasites found in 
ancient material should be considered in qualitative as well as 
in quantitative aspects. In the former case, the differential 
diagnosis rests on detectable microscopic differences of 
closely related taxa. For this purpose the best technique is 
scanning electron microscopy, which can reveal variations in 
the surface relief of eggs and larvae of helminths. A com- 
parative morphological study using this technique is pres- 
ently underway in our laboratory. It focuses on larvae of 
Ancylostomu duodenale and Necator americanus, the most 
common human hookworms whose desiccated forms cannot 
be easily separated with the light microscope. 

Diagnosis of some parasites depends on biometric evalua- 
tion. This includes the ova of Trichuris, the helminth most 
commonly found in South American coprolites, but also very 
common in European archcological deposits. These are 
being studied with some taxonomic techniques, such as the 
Student t-test, for small samples (Sokal and Rohlf 1969:223). 



The test was applied to the identification of eggs of this genus 
from small fragments of coprolites from South American 
sites (Confalonieri 1988) under circumstances in which mor- 
phological criteria to the identification of the fecal material 
cannot be used. In such cases in which several species of 
Trichuris have overlapping size ranges, including the human 
T. irichiura, the statistical procedure is useful since it indi- 
cates in probabilistic terms the possibility for human origin of 
the material. 

We are using, again with Trichuris eggs, a new biometric 
parameter for a better discrimination of the different species. 
This is the linear regression coefficient between length and 
width of the eggs, already used by Joyner and Norton (1980) 
in the specific diagnosis of protozoan oocysts. Thus we can 
add another variable for a more complete morphological 
evaluation of the egg of each species. This parameter was 
shown to be especially useful for the differential diagnosis of 
eggs of T. Irichiura and T. suis. two sister species commonly 
associated in archcological material from Europe (Jones 
1982). 

In summary, advances in techniques and methods applied 
to paleoparasitological investigation are the result of new 
approaches from biomedical and zoological sciences. In the 
future these will provide a greater reliability for identification 
of parasitic diseases in pre- and protohistorical populations. 

Literature cited 

Adamson, P.B. 1976. Schistosomiasis in Antiquity. Medical Histo- 
ry. 20:176-188. 

Araujo, A.J.G. 1987. Paleoepidemiologia da Ancilostomose. 
D.Sc. dissertation, Ensp, Fiocruz, Rio de Janeiro. 

Baer, J.G. 1971. Animal Parasites. New York: McGraw-Hill. 

Confalonieri, U.E.C. 1988. The Use of Statistical Test for the Iden- 
tification of Helminth Eggs in Coprolites. Paleopathology News- 
letter. 62:7-8. 

Confalonieri, U.E.C, B.M. Ribeiro-Filho, L.F. Ferreira, and 
A.J.G. Araujo. 1985. The Experimental Approach to Paleo- 
parasitology: Desiccation of Trichuris irichiura Eggs. Paleo- 
pathology Newsletter. 5 1 :9- 1 1 . 

Fferreira, L.R, A.J.G. Araujo, U.E.C. Confalonieri. 1979. Sub- 
si'dios para a Paleoparasitologia do Brasil I. Parasites En- 
contradosemCoprolitos noMunicipiodc Unaf. MG.ResumoslV 
Congresso Sociedade Brasileira Parasitologia. Campinas. 

Fry, G.F. 1977. Analysis of Prehistoric Coprolites from \Jli\\. An- 
thropological Papers, vol. 97. University of Utah. 

Home, P.D. 1986. Helminthiasis and Mummified Human Re- 
mains. Abstract. 13th annual meeting of the Paleopathology As- 
sociation, Albuquerque. New Mexico. 

Jones. A. KG. 1982. Human Parasite Remains: Prospects for a 
Quantitative Approach. In A.R. Hall and H.K. Kenward, eds.. 
Environmental Archeology in the Urban Context. Council for 
British Archeology Research Report. 43:66-70. 

Joyner. LP., and C.C. Norton. 1980. The F.imeiha acer\'ulina 
Complex: Problems of Differentiation of Eimeria acenulina. E. 
mitis and E. mivali. Protozoological Abstracts, 4:45-52. 



Zagrrb Paleopathology Symp. 1988 



78 » U.E.C. Confalonieri, L.F. Ferreira, A.J.G. Araujo, M. Chame, and B.M. Ribeiro Filho 

Lin. D.S.,W.E. Connor, L.K. Napton, and R.F. Heizer. 1978. The 
Steroids of 2000- Year-Old Human Coprolites. Journal of Lipid 
Reseunh. 19:215-221. 

Reinhard, K.J., U.E.C. Confalonieri, B. Herrmann, L.F. Ferreira, 
and A.J.G. Araujo. 1988. Aspects of Paleoparasitological Tech- 
nique: Recovery of Parasite Eggs from Coprolites and Latrines. 
Homo. 37:217-239. 

Ruffer, MA. 1910. Note on the Presence of "Bilharziahaematobia" 
in Egyptian Mummies of the Twentieth Dynasty (1250-1000 
B.C.). British MedicalJournal. 1:16. 

Sokal, R.R., and F.J. Rohlf. 1969. Biometry: The Principles and 
Practice of Statistics in Biological Research. San Francisco: 
W.H. Freeman. 

Zimmerman. M.R. 1972. Histological Examination of Experimen- 
tally Mummified Tissue. American Journal of Physical An- 
thropology. 37:271-280. 

1977. An Experimental Study of Mummification Pertinent 

to the Antiquity of Cancer. Cancer, 40:1358-1362. 

1978. An Experimental Base for Paleopathologic Diag- 



nosis. Transactions and Studies, College of Physicians of Phila- 
delphia. 45:299-305. 



Zagreb Paleopathology Symp. 1 9HH 



Taphonomy of spontaneous ("natural") 

mummification with applications to 

the mummies of Venzone, Italy 

Arthur C. Aufderheide and Mary L. Aufderheide 



Soft tissue preservation ("mummification") of human re- 
mains is of more than curious interest. Information of inter- 
pretive value applicable to epidemiology, parasitology, an- 
thropology, archeology, and many other fields has been 
extracted by appropriate laboratory technology applied to 
such tissues (Cockburn and Cockbum 1980:1-8). In most 
instances postmortem preservation of soft tissues is the result 
of specific, anthropogenic efforts directed at such an out- 
come. Methods have varied from evisceration and desicca- 
tion by heat in the Chinchorro culture of northern Chile 8000 
years ago (Allison et al. 1984) to the modem techniques 
using intra-arterial injection of protein-denaturing chemi- 
cals. 

While the effectiveness of the different methods varies, in 
most cases the principle of the technique employed is self- 
evident. However, in certain human mummies no evidence 
of anthropogenic, conservational effort is apparent, nor are 
the mechanisms involved in such apparently spontaneous 
mummification processes obvious (Fornaciari 1982). Some 
of these are desert burials where the combination of heat and 
the capillary action of sand are probably the principal ele- 
ments causing moisture removal from the body before soft 
tissue dissolution is completed (Cockbum and Cockburn 
1980:140). Many of the other cases, however, deal with hu- 
man bodies interred under conditions not normally expected 
to conserve soft tissues, such as subterranean tombs fre- 
quently carved out of rock, commonly beneath a church or 
other religious structure (Kleiss 1967:208), hence their col- 
lective appellation "catacomb mummies." 

This communication identifies the principal mechanisms 
involved in postmortem soft tissue lysis and the factors po- 
tentially available to cause "natural" mummification by re- 
tarding or arresting these processes. As an example, we ex- 
amine these possibilities in the case of sp<)ntanet)us 
mummification of a group of human mummies in Vcnzone, 
Italy. 



The report concludes with identification of specific defi- 
cits in our knowledge of such processes, and the research 
required to provide the information base necessary to under- 
stand the biological process of spontaneous mummification. 

Mechanisms inhibiting postmortem 
soft tissue lysis 

Normally, dissolution of soft tissues after death is achieved 
by enzymatic action. These enzymes are derived from three 
sources: (I) body tissues themselves, principally intracellu- 
lar enzymes, mostly of lysosomal origin; (2) bacteria, com- 
monly from the colon; and (3) insects from the environment. 
Properties shared by most enzymes include considerable 
specificity in the molecular stmcture of their substrate as well 
as a high degree of sensitivity to environmental changes of 
temperature or acidity (pH) and to the presence of heavy 
metal ions. Furthermore all enzymes need a liquid medium in 
which to operate. Prevention of postmortem soft tissue lysis 
("mummification") in any given situation can therefore be 
expected to involve one or more of these areas of vul- 
nerability resulting in partial or total inhibition of enzyme 
action. For example, one of the mentioned factors may pro- 
duce partial suppression of enzyme action, retarding the dis- 
solution rate sufficiently to permit an arid environment to 
desiccate the soft tissue and prevent further enzyme activity 
(Evans 1963:3-22). 

THERMAL ACTION 

Cooling and freezing to preserve perishable foods are part 
of our everyday experience. Not only the well-publicized 
mammoths of Siberia (Orslanov et al. 1980:1-5) but also 
human bodies have been preserved by this method. The latter 
include Greenland Eskimos (Hansen and Gurtler 1983), the 
"Prince of el Plomo" mummy from Chile — a nine-year-old 



Zagreb Paleopathology Symp. 1988 



79 



80 • Arthur C. Aufderheide and Mary L. Aufderheide 



sacrificial victim entombed above the frost Hne on an Andean 
mountain at an ahitude of 5400 m (Mostny 1957; Schobinger 
1966), Scythian tribal chiefs (Artamonov 1965) and Arctic 
expedition members (Beattie 1983; Paddock etal. 1970) bur- 
ied in tombs dug into permafrost areas. Although most of 
these were probably continuously frozen, cooling near but 
not necessarily below the freezing point (as in Arctic summer 
thaw periods) may inhibit enzyme action at least to the point 
of profound retardation, as it did in several 650-year-old Inuit 
bodies from Alaska (Zimmerman and Aufderheide 1984). Of 
interest here are Micozzi's experimental taphonomy studies 
demonstrating delayed soft tissue putrefaction at summer 
outdoor temperatures following a brief period of body freez- 
ing immediately after death (although the mechanical effects 
of freezing actually hastened disarticulation). Micozzi 
( 1 986) felt this was the result of substantial intestinal bacteri- 
al mortality during the period of freezing. 

Warming the body may also retard putrefactive chemical 
reactions. Since intestinal bacterial growth in vitro fre- 
quently ceases at incubation temperatures only a few degrees 
above body temperature, the delaying effect of wanning may 
be operative both at the bacterial level as well as creating an 
environmental temperature substantially deviant from the 
optimum for some enzymes. Heat generated by intestinal 
bacterial activity in a living individual is normally di.ssipated 
by intestinal wall blood flow. When this cooling flow of 
blood ceases after death, intra-abdominal temperatures have 
been shown to rise. Native Aleuts exploited this preserving 
effect by first heating their deceased tribal leaders' corpses 
over a fire and then placing them in a cave continuously 
warmed by a natural volcanic heat source (Alexander 1949; 
Zimmerman et al. 1981:640) In the southwestern United 
States, bodies of pre-Columbian North American natives 
were sometimes buried in stone-lined cists exposed to the hot 
summer sun. Conceivably, elevated ambient temperature 
may have been the principal factor in delaying putrefactive 
enzyme activity until the corpse became very dry (El-Najjar 
et al. 1985). Such effects probably require substantial tem- 
perature elevations since only mild rises, although perhaps 
inhibiting bacterial growth, may accelerate the proteolytic 
activity of certain enzymes. 

CHEMICAL ACTION 

There are few well-documented instances of spontaneous 
mummification largely due to an environmental al i eration 
OF pH, although this possibility is seldom pursued vigorously 
by investigators. The well-known tissue-preserving effect of 
encasing a corpse in highly alkaline, powdered lime testifies 
to its potential effectiveness. It is conceivable that water 
percolating through a limestone soil may become sufficiently 
basic to paralyze enzymatic activity when it saturates a body 
buried therein. 

Heavy metals are powerful enzyme poisons. This is, for 
example, the principal mechanism of lead toxicity in living 



individuals. Arsenic is so effective that it was used com- 
monly as an intra-arterial injection method of embalming by 
American morticians until the early part of this century 
(Snow and Reyman 1977). Arsenic was accumulated during 
life in the bodies of pre-Columbian natives of northern 
Chile's Camarones Valley as a result of drinking water from 
the valley's arsenic-contaminated river. This may have con- 
tributed to the excellent state of preservation present in these 
bodies (M.J. Allison, pers. comm.). 

The ABSENCE OF OXYGEN is commonly invoked as an ex- 
planation for postmortem soft tissue preservation, though it 
is difficult to identify a well-controlled, laboratory study 
establishing this conviction. The astonishing quality of soft 
tissue preservation in the body of a Chinese noblewoman 
from 100 B.C. has been attributed to the assumed anoxic tomb 
environment, though the assignment of oxygen absence as 
the principal factor in that case was done by exclusion of 
other apparent possibilities (Wu et al. 1980). 

In addition to the action of heavy metals and the chemical 
methods listed below, occasionally specific antimicrobial 
SUBSTANCES may be present which delay degenerative pro- 
cesses by inhibiting bacterial proliferation. Probably the best 
known of these is the production of tetracycline by the mold- 
like bacteria Streptomyces. Ingestion of this antibiotic by a 
living individual for infection control has been found to cause 
a specific, fluorescent staining of bone collagen. Detec- 
tion of a similar staining pattern in archeological (Nubian) 
bones (believed to be the result of eating Streptomyces- 
contaminated grain) demonstrated that accidental antibiotic 
ingestion occurred during antiquity (Bassett et al. 1980). 
Aspergillus fla\ us. which flourishes in grain, also produces a 
chemical with antibacterial action: aflatoxin. Theoretically 
such a mechanism might contribute to soft tissue preserva- 
tion after death. 

One reason living cells survive the frequently complex 
chemical milieu commonly present within intracellular en- 
vironments of living biological systems is that most enzymes 
are designed to respond to only a very narrow range of mo- 
lecular structures. This high degree of specificity for en- 
zymes' intended substrates makes possible the success of 
tissue preservation by the use of "fixing" substances like 
formaldehyde or certain alcohols which so radically re- 
arrange proteins' molecular contour that proteases which are 
commonly present post mortem no longer react with them. 
Tannic acid is a fixing agent commonly employed today by 
taxidermists to preserve animal skins. The presence of tannic 
acid in many northern European swamps is believed to be 
responsible for the frequently excellent preservation of the 
"bog people" mummies found within them (Glob 1965:1- 
45). 

Adipocere formation is initiated in the form of neutral 
fat hydrolysis by endogenous lipases subsequently modified 
by bacterial enzymes (usually of clostridial origin) resulting 
in the formation of a different group of fatty acids which are 
relatively insoluble and chemically poorly reactive. These 

Zagreb Paleopathology Symp. 1988 



Taphonomy of spontaneous mummification • 81 



may form a shell around the body surface, physically shield- 
ing the enclosed viscera from external influence and paralyz- 
ing further bacterial growth and enzymatic action internally 
by lowering the pH. These changes were thought to have 
been responsible for the preservation of two bodies sub- 
merged in water of known temperature for five years (Cotton 
etal. 1987). 

DESSICATION 

All enzymes can exert their action only in a fluid environ- 
ment. Hence, enzymatic tissue destruction can be prevented 
if sufficient water is removed from the tissue (desiccation), a 
principle employed commercially for preservation of fruit 
and other foods. In order to be the sole operating mechanism 
in natural mummification such water removal would need to 
occur quite rapidly. There may be occasional situations in 
which this could occur (prolonged exposure to the summer 
sun in Cairo, for example), but they must be exceptional, and 
most naturally mummified bodies are not found in circums- 
tances where this could have been exclusively operative. 
Burial conditions which would encourage removal of body 
fluids by conduction (capillary action) could be expected to 
accelerate the dehydration process in comparison to circums- 
tances dependent only on surface evaporation and convec- 
tion. For example, wrapping a corpse snugly in a wool 
blanket and interring it in sand may increase the rate of water 
removal from the body through the "wicking" etTect of the 
textiles and sand. Furthermore, if the body position is verti- 
cal, enzyme-laden small-intestinal fluids will drain out 
through the perineum, sparing the viscera of the upper abdo- 
men and chest. In spite of such enhancing conditions, how- 
ever, it is probable that in most cases at least partial suppres- 
sion of enzymatic action by one or more of the other, 
previously discussed mechanisms may need to operate in 
order to provide the time necessary for sufficient water re- 
moval from the tissues to prevent further enzymatic action by 
dehydration alone. 

The mummies at Venzone, Italy 

Resting at the junction of the Venzonassa Valley with that of 
the larger Tagliamento River, the small community of Ven- 
zone was strategically located to permit control of the flow of 
men and arms in ancient times to and from the Fruilian Plain 
through this narrow gap in the mountains of northeastern 
Italy near Trieste. Romans exploited its military virtue, but it 
was not until a.d. 1258 that the first stone of the wall pres- 
ently enclosing the village was laid. While feudal lords vied 
for her possession, Venzone's inhabitants were more con- 
cerned with the commercial and social activities of their 
neighboring (and competing) community, Gemona. When 
the latter erected a majestic cathedral, Venzonians expanded 
their small church of St. Andrew into a grand cathedral, 
consecrating it in 1338. Burial vaults constructed beneath its 

Zagreb Paltopalhology Symp. 1988 



Stone floor served as the final resting place for clerics and 
important citizens during the subsequent five centuries. One 
of these bodies, relocated during construction work in 1679, 
was found to be mummified and was hastily hidden protec- 
tively in the underground tombs. Later remodeling expanded 
the cathedral further. By the first quarter of the 19th century 
so many of the bodies in the subterranean church vaults had 
become mummified that they attracted the attention of a phy- 
sician from the nearby community of Udine. F.M. Mar- 
colini. a medical staff member of the Udine municipal hospi- 
tal, reviewed these mummies in 1829. carried out an autopsy 
on one of them, and published his findings, providing de- 
tailed descriptions of 17 of them, including the names and 
death dates of many ( 1 83 1 :42- 1 2 1 ). By 1 850, 27 mummies 
had been removed from the burial vaults, and eventually 
these were placed in glass-fronted display cabinets in the 
baptistery adjacent to the cathedral where they attracted the 
curiosity of many a visitor (Galassi 1950). 

Several mummies from this collection have been lost. One 
or two were transferred to Vienna shortly after Napoleon 
conquered the area and annexed it to Austria. Two are be- 
lieved to have been transported to a New York museum and 
two others to Rome or Padua. None of these have been lo- 
cated in recent times. In addition one was destroyed by Mar- 
colini's autopsy in 1829 (Galassi 1950). 

On 6 August 1950 Dr. A. Gallassi from the University of 
Bologna inspected the displayed mummies, compared them 
with Marcolini's descriptions and found little change other 
than the loss of hair from a red beard in mummy No. 5 (Sacer- 
dote Mistrozzi). He also added his own descriptions of an 
additional five mummies exhumed since Marcolini's visit 
(Galassi 1950). 

A total of 21 mummies continued to be displayed in the 
cathedral's baptistery until the tragedy of 1976. On May 6 of 
that year a vigorous earthquake centered near Venzone 
caused considerable damage to the area, but a second one on 
September 15 was of catastrophic violence and nearly lev- 
eled most of the buildings in this unfortunate community. Not 
only much of the cathedral but also the entire baptistery 
collapsed, partially or completely burying many of the en- 
closed mummies. A local naturalist led several volunteers in 
a mummy recovery effort. About half of the 22 bodies were 
found reasonably intact. The remainder were disrupted, 
sometimes extensively. Some of the dismembered mummies 
were reassembled with the aid of pre-earthquake photos, but 
it was fwssible to salvage only a total of 15 of the 22 damaged 
bodies. Exposure to the elements had resulted in some appar- 
ent dampness of the skin in many. Fearing bacterial or fungal 
growth, the restoring party washed the bodies with a mixture 
of formalin and phenol, storing them in a room whose walls 
they washed with a similar solution. Further suppression of 
microorganismal growth was achieved by lining the floor and 
part of the room with formalin-soaked newspapers. Subse- 
quently the mummies were transferred to a metal hut where 
they have been displayed during the period of community 



82 • Arthur C. Aufderheide and Mary L. Aufderheide 



reconstruction until a building to house them permanently 
has been completed (Mainardis 1983). 

When the cathedral was reconstructed and expanded in the 
14th century the new floor level was raised 1 .5 m. Most of 
the tombs 1 1 through 1 7 are constructed between the original 
floor level and that of the new. current one; the bottom of 
these tombs, therefore, is sealed by the original stone floor 
(Anonymous 1971:96). Tombs 1 through 10, however, were 
constructed under the floor level of the new, expanded por- 
tion and the bottom of these tombs consists only of soil. 
Interestingly, while skeletonized bodies were present in all 
tombs, mummies were found only in tomb numbers 1 
through 10. 

During periods of heavy rainfall and high stream levels, 
standing water has been observed in the tombs containing 
mummies, and such an occasion led the residents to remove 
the mummies from the tombs when they found some of the 
wood coffins flooded and a white fungus partially covering 
the surface of many of the mummified bodies within them. 
About 1829, B. Biasoletto, director of the Botanical Garden 
at Trieste, examined the mummies and identified the fungus 
as Hypha hombycina Pers., suggesting that the fungal 
growth, by extracting water from the bodies, may have been 
responsible for the process of natural mummification in these 
cadavers. Except for Marcolini's (1831) suggestion of the 
action of an acid gas from the soil and some adipocere forma- 
tion. Biasoletto's suggestions have remained the locally ac- 
cepted explanation of their mummification. 

MATERIALS AND METHODS 

Having obtained permission to view the mummies from the 
proper local authorities, the authors visited Venzone, Italy on 
13 December 1983. No permission to biopsy or dissect the 
bodies was requested and no such procedures were carried 
out. Local archeologists. naturalists, historians, and re- 
sidents with knowledge about the mummies and their tombs 
were interviewed. The mummies were inspected and two 
(numbers 1 and 8) were cultured for fungi by swabbing their 
facial skin and exposed leg muscle surface with sterile cotton 
and streaking these on slants of Sabouraud's agar tubes. 
These were incubated at room temperature for up to .several 
months. Material from growth was transplanted into individ- 
ual Sabouraud's agar tubes and onto slide cultures. Micro- 
scopic examination of slide cultures and wet slide prepara- 
tions, together with gross culture characteristics, provided 
evidence for identification. A sample of light-gray sand and 
fine gravel soil from a recent building excavation adjacent to 
the cathedral was procured after scraping away 5 cm of soil 
from the vertical face of the excavated pit wall at a depth of 22 
cm from the ground surface level. 

The roofs of many of the tombs in the front of the church 
had collapsed during the earthquake and were sealed with 
cement slabs for safety reasons, but the cavity of tomb 9 was 



filled with debris, exposing only a part of its intact roof. 
Samples of wood and brick were removed from the exposed 
roof of this tomb in the cathedral. Access to tomb 15 was 
possible by removing its temporary wooden cover and de- 
scending cement steps leading to its interior. This was oc- 
cupied by a jumble of disintegrated and collapsed wooden 
coffins. Individual human bones were scattered throughout 
this conglomeration, mixed with a damp, powdery material 
which also lined the floor under the coffins. Only soil at the 
foot of the steps, away from the coffms, was dry and light 
grey, similar to the soil in the excavation pit adjacent to the 
cathedral. No stone floor was identifiable. Coffin wood and 
floor soil were sampled from tomb 15. These samples were 
also weighed, then dried to constant weight and their mois- 
ture content calculated. Soil specimens were analyzed for 
lead content by graphite furnace atomic absorption spec- 
trometry (Wittmers et al. 1981), and for mercury, arsenic, 
copper and cobalt by neutron activation analysis (the latter 
by Technical Services Laboratory, Mississauga, Ontario, 
Canada). Soil pH was determined by suspending the soil in 
distilled water and measuring the pH of the mixture with a 
Coming pH meter (McLean 1980). Swabs of the coffin 
boards in tomb 1 5 and of the soil samples were also prepared 
for fungus cultures as described above. 
Analytical results are itemized in Table 1 . 



DISCUSSION 

The geological structure of the Venzone area is almost en- 
tirely that of calcareous rocks (Mainardis 1976: 16). The high 
carbonate content of the soil adjacent to the church and that 
composing the floor of tomb 15 (Table 1) is consistent with 
limestone. Surface and ground waters of such areas normally 
are quite alkaline. The pH values of samples listed in Table 1 . 
however, range from neutrality to 6.0. This is probably a 
local phenomenon secondary to industrial and other an- 
thropogenic acidic products affecting the soil sampled out- 
side of and adjacent to the church, while that of the tomb 
floor was undoubtedly contaminated with acidic tissue prod- 
ucts from multiple degenerating bodies. The neutral or 
slightly acidic values in these particular samples do not ex- 
clude an alkaline pH effect on tissue enzymes resulting from 
periodic tomb flooding by ground water seeping through 
limestone. 

Similarly, moisture content of the "dark" soil sample from 
the tomb floor is high. Since the normal soil color of this area 
is light grey, the dark color of this soil sample from beneath 
the collapsed cotTins undoubtedly reflects substantial con- 
tamination with degenerating human tissue. The relatively 
low moisture content of the boards and that of the bricks in 
the tomb roof probably more accurately reflect the normal 
state of humidity in an empty tomb lined by normally hydro- 
philic dolomite rock and soil, as suggested by the nearly 



Zagreb Pult'opalholofiy Symp. I9fi8 



Taphonomy of spontaneous mummification 


•83 


Table 1. Analytical results of studies performed on samples relating to mummies at Venzone, Italy 




Moisture Heavy metals (ppm) 
Sample Fungus culture content % pH Pb As Hg Cu Co Carbonate 





Skin, 


Penicillium sp. 


- 


- 


mummy #1 








Skin, 


Bacillus (strep.) 


- 


- 


mummy #8 








Soil, 


Microascus sp. 


1 


6.5 


excavation 








Soil D, floor, 


Trichoderma sp. 


47 


6.0 


Tomb 15 








Soil L, floor, 


No growth 


14 


6.5 


Tomb 15 








Coffm board, 


Scedosporium sp. 


7 


- 


Tomb 15 








Brick roof. 


Trichoderma sp. 


9 


6.8 


Tomb 9 


Penicillium sp. 







.76 .161 19 16 Moderate 



460 L2 1.64 346 .62 



94 .90 .608 26 13 High 



17 - . - - High 



absent moisture in the soil sample from adjacent to the 
church. This could be a factor contributing to the dehydration 
of a body whose postmortem, enzymatic tissue digestion had 
been delayed by some other factor. 

Contamination of Venzone area soils by common heavy 
metals is clearly absent, as seen in the listed analytical values 
of the sample from adjacent to the church. The dark soil of 
the floor from tomb 1 5 immediately below the coffins reveals 
contamination by lead (460 ppm) and copper (346 ppm). The 
latter is a known, powerful, enzymatic poison, and it is a 
common archeological experience to find human soft tissue 
preserved adjacent to a copper ornament, such as a bracelet, 
on an otherwise skeletonized body. While our observation 
circumstances did not permit a thorough search of the tomb 
content, both lead and copper items were common compo- 
nents of coffins or their contained artifacts since medieval 
times, and thus are the most likely source of these con- 
taminating elements. 

The fungus cultures are of special interest. Many of the 
mummies were partially covered with a white fungus at the 
time of their exhumation. Biasoletto's concept (1829?), at- 
tributing the desiccated state of the mummies' tissues to the 
dehydrating effect of growth of the fungus "Hypha bom- 
bacina," has become a permanent part of local folklore. 
Since this terminology is no longer used, it was necessary to 
peruse 19th century mycological taxonomy texts to obtain a 
description of the organism to which this label was applied. 
An 1822 publication (see Appendix) suggests this name was 
created by Pcrsoon ( 1 822:64) and persisted at least until 1 899 



(Saccardo 1899:1 192). It was used to describe a white, fluffy, 
cottony or silky mycelial growth without conidia. Unfortu- 
nately, this description is too nonspecific to permit its assign- 
ment within the modem system of mycological taxonomy. 
The fungi cultured from the various sources listed in Table 
I do not include any which demonstrate the growth charac- 
teristics listed under the rubric "Hypha bombycina" in the 
older texts. Indeed, they represent common household and 
soil fungi. The formaldehyde and phenol treatment of the 
bodies following the earthquake as described above can be 
expected to have destroyed fungi and probably also their 
spores previously present in or on the bodies, but if fungi 
meeting the description of "Hypha bombycina" had played a 
significant role in the mummification of the bodies in the 
various tombs, it would seem reasonable to anticipate their 
abundant presence in the soil samples and on the tomb con- 
tents. Of the organisms recovered from our sample cultures, 
only Penicillium is known to produce an antibiotic substance. 
While penicillin is effective against many gram-positive bac- 
teria, including the Clostridia commonly present in feces, it 
does not inhibit the growth of most gram-negative organisms 
including Escherichia coli. the most numerous stool inhabi- 
tant. It is also common hospital experience that therapeutic 
tissue concentrations of penicillin at the time of death do not 
prevent postmortem tissue degeneration. Postmortem fungal 
growth is extremely common on tissues of exposed, de- 
generating bodies after autogenous, bacterial, and insect en- 
zymatic action has acidified the tissues (Kvans 1963:4). Such 
growth, however, almost invariably restricts itself to exposed 



Zagreb Paleopathology Symp. 1988 



84 • Arthur C. Aufderheide and Mary L. Aufderheide 



surfaces and is thus unable to exert any significant preserving 
effect on deeper tissues. It appears improbable to us that 
fungal growth contributed significantly to the desiccated 
state of the Venzone mummies. 

The mummy bodies were examined (limited to inspection) 
for gross evidence of molecular alteration of proteins and/or 
fat to a chemically inert state. Facial features were frequently 
reasonably intact. The skin over the thorax was riddled with 
insect holes but was generally otherwise intact in many mum- 
mies. The anterior abdominal wall was frequently partially or 
completely absent; in these the exposed abdominal cavity 
rarely contained recognizable organs. Tissues comprising 
the perineum, gluteal areas, medial aspect of the thighs and 
posterior trunk were absent in most of the mummies — a 
pattern commonly present in naturally mummified bodies 
placed in a supine position post mortem and reflecting the 
gravitational distribution of enzyme-rich, intestinal digestive 
fluids. While admittedly adipocere formation is not always 
obvious, only a few, focal areas (primarily facial) could be 
identified which conceivably could represent such an altera- 
tion of fat . Certainly we could not confirm that the bulk of the 
tissue preservation was the consequence of a shell of protec- 
tive adipocere formation, nor was there any recognizable 
evidence of chemical protein fixation. The general condition 
of the mummies surviving the earthquake was similar to that 
described by Gallassi in 1950. 

It appears unlikely that tomb temperatures ever reach the 
freezing point. Midwinter temperature measurement (made 
by the authors) of a sealed, nearly identical tomb beneath the 
stone floor of the church in a nearby community of Urbania 
was 18°C. 

In summary, consideration of factors possibly contributing 
to the natural mummification of these bodies suggests it is 
conceivable, though not established, that highly alkaline 
ground water seeping through the surrounding area limestone 
intermittently may gain access through the soil floors to these 
bodies' tombs (though not as readily to the tombs with stone 
floors in the rear of the church), transiently immersing the 
corpses and raising their tissue pH at least temporarily to a 
degree sufficient to retard enzymatic .soft tissue destruction 
for a period long enough to permit subsequent tissue desicca- 
tion by the hydrophilic effect of the dolomite soil. Alter- 
natively, postmortem enzymatic action on tissues could have 
been paralyzed by the presence of heavy metals or by acidic 
action from degenerating textiles or other artifacts like cop- 
per, probably from coffin components or included contents 
(since area soils do not reveal excess quantities of at least the 
more common heavy metals). Cool but not frigid ambient 
temperatures may have enhanced retardation of soft tissue 
degeneration during winter burials, but it appears highly un- 
likely that natural preservation of these bodies was achieved 
through extreme thermal action (freezing or very high tem- 
peratures), by the mechanism of anoxia, by protein fixation 
or significant adipocere formation, nor by the dehydrating or 



antibiotic action of any fungus, including that of the organ- 
ism termed "Hypha bombycina." 

In brief, while application of our current information (re- 
garding spontaneous mummification) to the Venzone mum- 
mies makes certain possibilities more conceivable than oth- 
ers, it is not possible to establish the locally operative 
mechanisms with a desirable degree of certainty. Clearly, 
more precise predictions of such events will require a much 
more detailed understanding of postmortem changes, made 
possible by a program of laboratory investigation designed 
for that purpose. 

Research needs 

Presently, bodies preserved by spontaneous mummification 
represent the most valuable form of human remains for bio- 
medical and anthropological study, since they retain the 
organs bearing the anatomical, biochemical, immunological 
or microbiological evidence of the disease afflicting them, 
including the final, fatal episode. Postmortem degenerative 
processes place constraints on the ability of our modem labo- 
ratory methods to extract the desired information from these 
tissues. Detailed knowledge of these postmortem changes 
would permit us to adapt our technology so as to maximize 
the informational return. 

The broad generalizations necessary in the previous dis- 
cussion as well as our inability to identify unequivocally the 
mechanisms producing the Venzone mummies reflect the 
relatively barren state of our knowledge about postmortem 
human tissue changes. In a few, restricted areas isolated re- 
ports permit the synthesis of at least a proposed chemical 
sequence leading to a specific preservational product 
(adipocere) (Cotton et al. 1987), but every mechanism dis- 
cussed here needs to be studied in detail by developing an 
appropriate operational model in which the individual vari- 
ables of interest can be controlled. Measurement methods for 
the various reactions studied need to be created. Effects of the 
individual factors impeding or enhancing these reactions 
need to be identified and quantified. Following this the re- 
sults obtained in isolated tissue under controlled circums- 
tances then need to be evaluated under the infinitely more 
complex, field situations of the entire organism. While the 
"chemistry of death" (Evans 196.3: 1-87) is surely a compli- 
cated matter, it may be no more so than many which have 
been well defined in living organisms. 

Our understanding of postmortem tissue changes and the 
factors affecting them will only be achieved by such orderly 
investigations. Field observations unsupported by the con- 
trolled studies described above rarely provide information 
applicable to situations occurring under different circums- 
tances. Funding necessary to carry out such studies may be 
justified by the obvious applications of the derived data to 
everyday forensic problems of enormous medico-legal im- 
portance. 



Zagreb Paleopathology Symp. 1988 



Taphonomy of spontaneous mummification • 85 



Appendix 

The authors arc very grateful to John Rippon, Ph.D.. Section of 
Dermatology. Department of Medicine. University of Chicago and 
Pritzker School of Medicine, for the following information. 

In Mycologia Europaea. Vol. 1 , by Persoon. published in 1822. 
the following entry is found on page 65: 

Classis prima, Ordo primus; 

XXXV. Hypha. Flocciformis, mollissima ad tactum diffluens. 
fugax. Obs. Fungi sunt subterranei. aut in locis suf- 
focatis et cryptis vegetant. colore plerumquc albi. 
I . bombycina, subrotunda indeterminata. humida Ooccos 
gossypinos referens Hyphasma floccosum. Rehenti.sch. 
Flor. p.396. Dill. Hist. Muse. p.5,t.I.f.9. Dematium 
bombycinum. Syn. fung. 6%. Hab in fodinis et ccllis, 
ligms et lapidibus adhaerens. Colore nivea . . . 

In Sylloge Fungorum. Vol.14, by P.A. Saccardo, published m 
Pavia, 1899, by the author, the following entry is found on page 
1192: 

Mycelia sterilia, Hypha; 

HYPHA Pers. M.E.I, p.63, Hyphasma Rebent. Dematium Pars. 

Byssus L. pr. pr. ex emend. 

Humb.Dub. (Etym. hyphe texture). 
— Rhabdi arachnoidei hyalini simplices v. ramosi. decum- 
bcntcs, fistulosi, continui, laxe intertexti, fugaces (aeris 
contactu saltem) contabescentes v. confluentes. sporis de- 
stitute Mycetes subterranei in cryptis locisque sufFocatis, 
vegcti albi, aliorum procul dubie initia, ex loco lucisque 
defectu pessumdati. hinc dubii. 

I. Hypha bombycina Pers. M.E.I, p.63, Byssus floccosa 
Schreb. Spic. 144, B. bombycina Nees Syst. f. 73, 
Hyphasma floccosum Rebent. Neom. p.396. Dematium 
bombycinum Pers. Syn. p.696. Dill. Hist. t.I.f.9— Rhabdis 
hyphoideis, simplicissimis, subparallelis, niveis, primum 
laxe intertextis, hypham veluti gossypinam. elatam subro- 
tundam, mundissimam, dein collapsis, membranam com- 
pactam seu corium tenacellum mentientibus. Hab. ad ligna 
et alpides in caveis udis et fodinis minime rara in 
Germania. — 18-20 cm. alta et lata, ocissime gliscens. 



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Summary of audience discussion: In Israel a monk buried with 
intact clothing has been disinterred and found to be marvelously 
preserved. Other areas where spontaneous mummification has oc- 
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Zofin'h Pula'pathol(\i;\ Svmp. 19HS 



Soft tissue calcifications in paleopathology 



C.-A. Baud and Christiane Kramar 



C^alcified masses are rarely described in paleopathological 
literature (because they are perhaps not always found). As 
their origin (Table I) and their interest may be varied, it is 
important, in the presence of cxtraskeletal calcifications, to 
distinguish ectopic ossifications, tissue calcifications, and 
calculi. 

The diagnosis of some calcifications, owing to their at- 
tachment to the skeleton, is easy: for example, the stylohyoid 
ligament (O'Carroll 1984), costal cartilages (McCormick 
1980) and myositisossificans(Lagier and Baud 1978). When 
calcifications are isolated, but identifiable owing to their 
shape, diagnosis is also easy: the laryngeal cartilages ( Jurik 
1984), for example. When calcifications are not attached to 
the skeleton and are without anatomical shape, the diagnosis 
is harder. As such examples we present pleural plaques, 
leiomyomas of the uterus, a tuberculous lymph node, and a 
hydatid cyst. 

Material and methods 

Pleural plaques were found with the osseous remains of men 
from three different medieval cemeteries; Collonge, Geneva, 
Switzerland, 10-1 Ic, grave 45, man of more than 60 years 
old (Baud 1972; Bonnet 1972); St. Matthieu's Church, 
Bemex, Geneva, Switzerland, 13- 14c, grave 44, man of 60 
years old (Kramar 1984), and St. Gervais, Geneva, Switzer- 
land, grave 27. 

The first leiomyoma of the uterus was found among human 
skeletal remains from a Middle Neolithic population, 
Corseaux-sur-Vevey, Vaud, Switzerland, 4700-3490 B.C. 
(Kramar 1982; Kramar et al. 1983). The two others are from 
Early Middle Ages cemeteries: Sion Sous-le-Scex. Valais. 
Switzerland, 5- 10c, grave 37 and Ranees, Vaud, Switzer- 
land, 5-7c. 

The lymph node was found in a collective burial from the 
Chalcolithic period. Dolmen des Peirieres, Villedubert, 
Aude, France (Roudil 1976). 

The hydatid cyst was found with the remains of a medieval 
child 2-4 years old. 

All concretions were first macroscopically and radio- 
logically observed. Fragments of concretions were embed- 
ded in methyl methacrylate and sectioned for microscopic 

Zagreb Paleopathology Symp. 1988 



examination in normal and polarized light. Ground sections 
10 jjL thick were decalcified in formaldehyde-formic acid and 
stained with van Gieson's picrofuchsine. 

Microradiographs were made from sections 100 jx thick, 
according to the technique of Boivin and Baud (1984). Frag- 
ments from the 100-^, sections were reembedded in epoxy 
resin (Epon) forelectron microscopic examination. Ultrathin 
sections were decalcified and stained with phosphotungstic 
acid. 

An x-ray powder diffraction analysis was performed with a 
Guinier camera to determine the crystalline species, and an 
x-ray diffractometric recording, following the technique of 
Jacquet et al. (1980), for crystal size and/or perfection esti- 
mate. 

Results 

PLEURAL PLAQUES 

Macroscopically the pleural plaques were hard, of variable 
size ( 14.5 X 1 3 cm the biggest; 7.5 x 4.5 cm the smallest; 4- 
5 mm thick), with an irregular surface structure. Radiographs 
reflected these differences with a disparity of absorption. 

Table l. Examples and etiology of 
some soft tissue calcification 



Etiology 



Examples 



DevtlopmentaJ 
Aging 

Immobilization 

Trauma 

Inflammatory 

Tumoral 



Stylohyoid ligament 
Crowned odontoid 

Laryngeal cartilages 
Costal cartilages 

Articular tissues 

Myositis ossificans 

Pleural plaques 
Lymph node 
Hydatid cysts 

Leiomyoma 



87 



88 • C.-A. Baud and Christiane Kramar 



The microradiographs showed large areas with a high and 
uniform degree of mineralization, and others characterized 
by a lower degree of mineralization and the presence of some 
lens-shaf)ed cavities of the size of the bone osteocytic la- 
cunae. Examination of the decalcified sections showed areas 
stained red with van Gieson's method, fibrillar texture, and 
(jositive birefringence. Electron microscopic study indicated 
the presence of collagen fibrils with characteristic striation; 
these fibrils were scattered in highly mineralized zones and 
packed close in a parallel direction in the less mineralized 
ones. 

X-ray diffraction patterns were characteristic of apatite, 
with large crystals in the more mineralized zones (fine lines) 
and small crystals in the others (broad lines). 

After dissolution of apatite, we looked at the presence of 
minerals known to provoke fibroses (Le Bouffant 1974): we 
found nothing to support the hypothesis that minerals in the 
environment of these individuals are agents in this etiology 
(Constantopoulos et al. 1985). 



LEIOMYOMAS OF THE UTERUS 

Macroscopically the Neolithic leiomyoma was a spherical 
mass (56 x 52 x 45 mm) with a smooth but irregular surface. 
X-rays confirmed its mineralized nature. Examination of the 
decalcified sections showed the presence of collagen fibers; 
van Gieson's method stained them in red, and birefringence 
was positive; no bone structure was observed. Microradio- 
graphs showed a high and uniform mineralization. Electron 
microscopy confirmed the presence of collagen fibrils with 
the characteristic striation. The mineral material was apatite; 
crystal size and/or perfection were good. 

The dimensions of the two others were 46 x 32 x 25 mm 
(Sion Sous-le-Scex) and 30 x 26 x 18 mm (Ranees). The 
section of these calcifications showed the characteristic 
whorllike pattern of the leiomyoma (Bartholomew et al. 
1961). 

A similar case of calcified uterine leiomyoma was reported 
by Strouhal and Jungwirth (1977). 



LYMPH NODE 

The lymph node was a reniform mass (12x8 mm) with a 
lamellar capsule with numerous perforations enclosing two 
rounded nodules. Microradiographs of the sections showed 
that both capsule and nodules were highly mineralized. His- 
tological study of decalcified sections showed fibrillar struc- 
ture with a positive birefringence and a red van Gieson's 
staining, particularly in the surface layers of the node. X-ray 
diffraction revealed two mineral components: apatite in the 
periphery, and apatite together with whitlockite in the center, 
as we observe in calcified tuberculous lesions (Lindgren 
1961:81-89;Lagieretal. 1966; Sakae and Yamamoto 1987). 



The shape, size, and fibrous capsule with numerous perfora- 
tions suggest a lymph node; calcified foci formed of apatite 
and whitlockite suggest calcification of tuberculous origin. 

HYDATID CYST 

The cyst was an ovoid, hollow concretion 1 cm in diameter, 
with a smooth internal surface and an irregular external sur- 
face. The observation of a section with polarized light 
showed tangled collagen fibrils. All these facts characterize 
a cyst wall (Weiss and M0ller-Christensen 1971; Price 
1975:366-367; Wells and Dallas 1976; Ortner and Putschar 
1981). 

The mineral component was apatite only; this is compat- 
ible with an hydatid cyst (Lagier et al. 1966: 158). 

Differential diagnosis of soft tissue 
calcifications 

It is important to distinguish between ossifications, calcifica- 
tions, and calculi. 

We have first to differentiate tissue calcifications from 
calculi. Concretions in the body cavities (gastroliths, entero- 
liths, bezoars, etc.) and calculi in excretory ducts (salivary, 
biliary, urinary) also contain an organic matrix (Kahn and 
Hackett 1984), but in small quantity and not of collagenous 
nature (not stained with van Gieson's picrofuchsine). 

Among tissue calcifications we have to distinguish be- 
tween a calcification and an ossification: calcification corre- 
sponds to adeposit of mineral material in aconnective tissue, 
more or less altered, which shows the presence of scattered 
collagen fibrils and a very high degree of mineralization; 
ossification has a characteristic texture with an oriented dis- 
position of collagen fibrils and osteocytic lacunae. We have 
to note that a tissue calcification tends to be replaced by an 
ossification (Kuhlmann 1934), which explains the coexis- 
tence, in pleural plaques, of ossified zones and calcified 
zones. 

The study of the mineral component of a calcification can 
permit the substantiation of an etiological diagnosis: most of 
the soft tissue calcifications are formed of apatite only, and 
they correspond to a broad spectrum of pathological condi- 
tions (Lagier et al. 1966:158). Mixed crystal deposits, with 
apatite and whitlockite, are found predominantly in lesions 
of tuberculous or parasitic origin (Lagier et al. 1966:159). 

Literature cited 

Bartholomew, L.G., J.C. Cain, G.D. Davis, and A.H. Bulbulian. 
1961 . Misleading Calcific Shadows in the Abdomen. Postgradu- 
ate Medicine. 30:51-52. 

Baud, C.-A. 1972. Unc Plaque Pleurale Calcifiee: Etude Ultra- 
structurale et Cristallographique. Genava. 20:196-199. 

Boivin, G., andC.-A. Baud. 1984. Microradiographic Methods for 
Calcified Tissues. In G.R. Dickson, ed., Methods of Calcified 



Zagreb Pateopaiholofiy Symp. 1988 



Soft tissue calcifications in paleopathology • 89 



Tissue Preparation. 391-412. New York: Elsevier Science Pub- 
lishers. B.V. 

Bonnet, C. 1972. L'Ancicnne Eglisc de Collonge (Collonge- 
Bellcrive. Geneve). Geneva. 20:131-203. 

Constantopoulos, S.H.. J. A. Goudevenos, N. Saratzis, A.M. Lun- 
ger, l.J. Seiikoff, and H.M. Moutsopoulos. 1985. Metsovo Lung: 
Pleura! Calcification and Restrictive Lung Function in North- 
western Greece. Environmental Exposure to Mineral Fiber as 
Etiology. Environmental Research. 38:319-331. 

Jacquet, J. J.M. Very, and H.D. Flack. 1980. The 2 Determination 
of Diffraction Peaks from "Poor" Powder Samples: Application 
to Biological Apatite. Journal of Applied Crystallography, 
13:380-384. 

Jurik, A.G. 1984. Ossification and Calcification of the Laryngeal 
Skeleton. Acta Radiologica. 25:17-22. 

Kahn, S.R., and R.L. Hackett. 1984. Microstructure of Decalcified 
Human Calcium Oxalate Urinary Stones. Scanning Electron Mi- 
croscopy. 2:935-941. 

Kramar, C. 1982. La Necropole de Corseaux-sur-Vevey: Etude An- 
thropologique et Description Archeologique. These 2041, 
Geneve. 

1984. Plaques Pleurales Chez un Homme du Moyen Age: 

Etude Radiologique, Microscopique et Cristallographique. Fifth 
European Meeting of the Paleopathology Association, 199-210. 
Siena, Italy. 

Kramar, C, C.-A. Baud, and R. Lagier. 1983. Presumed Calcified 
Leiomyoma of the Uterus. Archives of Pathology and Laboratory 
Medicine. 107:91-93. 

Kuhlmann, K. 1934. Zur Atiologie, Entstehung und Bedeutung der 
Pleuraverkalkungen bzw. Pleuraverknocherungen. Fortschritte 
aufdem Gebiete der Rontgenstrahlen. 49:147-154. 

Lagier, R.. and C.-A. Baud. 1978. Some Comments on Paleopa- 
thology Suggested by a Case of Myositis Ossificans Circumscrip- 
ta Observed on a Medieval Skeleton. Journal of Human Evolu- 
tion. 9:9-13. 

Lagier, R., C.-A. Baud, and M. Buchs. 1966. Crystallographic 
Identification of Calcium Deposits as Regards Their Pathological 
Nature, with Special Reference to Chondrocalcinosis. In H. 
Fleisch, H.J.J. Blackwood, and M. Owen, eds.. Third European 
Symposium on Calcified Tissues. 158-162. New York: Springer- 
Verlag. 

Le Bouffant. L. 1974. Investigation and Analysis of Asbestos Fi- 
bers and Accompanying Minerals in Biological Materials. En- 
vironmental Health Perspectives. 9:149-153. 



Lindgren, I. 1961. Anatomical and Roentgenologic Studies of Tu- 
berculous Infections in BCG- Vaccinated and Non-Vaccinated 
Subjects. With Biophysical Investigations of Calcified Foci. Acta 
Radiologica (supplemcntum) 209: 1 - 101 . Stockholm. 

McCormick, W.F. 1980. Mineralization of the Costal Cartilages as 
an Indicator of Age: Preliminary Observations. yourna/o/Foren- 
■wc- Sciences, 25:736-741 . 

O'Carroll, M.K. 1984. Calcification in the Stylohyoid Ligament. 
Oral Surgery, 58:617-621. 

Ortner, D.J., and W.G.J. Putschar. 1981. Identification of Patho- 
logical Conditions in Human Skeletal Remains. Smithsonian 
Contributions to Anthropology. 28:229-233. Washington, D.C.: 
Smithsonian Institution Press. 

Price, J.L. 1975. The Radiology of Excavated Saxon and Medieval 
Human Remains from Winchester. Clinical Radiology. 26:363- 
370. 

Roudil. J.-L. 1976. Villedubert, Les Peirieres. Informations Arch- 
eologiques. Gallia Prehistoire. 19:553-555. 

Sakae, T., and H. Yamamoto. 1987. Crystals and Calcification 
Patterns in Two Lymph Node Calcifications. Journal of Oral 
Pathology 16:456-462. 

Sirouhal, E., and J. Jungwirth. 1977. Ein verkalktes Myoma uteri 
aus der spatcn Romerzeit in Acgyptisch-Nubien. Milteilungen 
der Anthropologischen Gesellschaft. 107:215-221. Vienna. 

Weiss, D.L., and V. Moller-Christensen. 1971. Leprosy, Echi- 
nococcosis and Amulets: A Study of a Medieval Danish Inhuma- 
tion. Medical History. 1 5 : 260- 267 . 

Wells, C, and C. Dallas. 1976. Romano-British Pathology. Antiq- 
uity, 50:53-55. 



Summary of audience discussion: Interpretation of crystal 
characteristics of excavated calcified material is most useful if its 
location within the body is known precisely. In the thorax, for 
example, it becomes more informative if it can be determined 
whether the calcified mass represents simple exudate or a pleural 
plaque and whether costal periostitis was present. Archcologists 
need to be made aware of the importance inherent in such detailed 
observations. Since Dr. Brothwell has observed bacteria in dental 
plaque specimens viewed by scanning electron microscopy, a simi- 
lar search for mycobacteria in calcified material suspected to be of 
tuberculous origin appears desirable, as well as diagnostic immu- 
nological studies on protein included within calcified material. 



Zagreb Paleopathology Symp. 1 988 



Technological innovations and discoveries in the 
investigation of ancient preserved man 



Peter K. Lewin 



Stereoscan imaging from composite 
"CT scans" 

Late in 1976 when the first computeinzed axial x-ray to- 
mographic machine (CT scan) was installed at the Hospital 
for Sick Children in Toronto. Dr. Harwood-Nash and I per- 
formed the first CT scan on an archeological specimen 
(Lewin and Harwood-Nash 1977). The specimen was the 
desiccated brain from Nakht, an adolescent weaver from the 
funerary chapel of Setnakht, who had lived in Thebes about 
3000 years ago. The images from Nakht 's brain demon- 
strated intact ventricular cavities and partial differentiation of 
the grey and white areas of the brain together with small 
postmortem cavities. 

The brain scan was followed by the first total body scan of 
the mummy of the priestess Djema "Etes' Ankh, dating from 
about ninth century B.C. Tomographic sections of the head 
showed prosthetic artificial eyes set in the eye sockets. Sec- 
tions through the pelvis showed normal hip joints, and within 
the pelvis the remains of the uterus could be visualized 
(Lewin 1978). 

In the last two years in collaboration with John Stevens and 
Judy Trogadis at Toronto Western Hospital, who developed 
the computer software for this project (Stevens and Trogadis 
1986), we have extended our noninvasive imaging tech- 
niques by constructing three-dimensional images from se- 
quential data obtained by the two-dimensional CT scan. 

A beautifully preserved head from the Greco-Roman 
period is shown in Figure 1 . Composite spacial see-through 
reconstructions of ancient archeological specimens, using 
computed axial tomograms, are presented in Figures 2 and 3. 

This technique can also be applied to other imaging meth- 
ods and enhanced with newer, digital processors. These new, 
nondestructive imaging methods would be invaluable in the 
three-dimensional examination of mummified remains and 
their internal structures including archeological objects, 
keeping these valuable specimens intact for posterity. 
90 




Figure I. Ancient Egyptian mummified head from 
Greco-Roman Period. 

Electron microscopy of mummified tissues to 
demonstrate viral agents and their possible 
viability 

Ancient Egyptian mummified material was first examined at 
the ultrastructural level in 1966 (Lewin 1967) and demon- 
strated reasonable preservation of cellular organelles. Since 
then numerous tissues have been examined by electron mi- 
croscopy, the best preserved tissues often being skin, blood, 
muscles, and vessels. 

Viral agents have also been demonstrated, including 
smallpox-like particles from the mummy of Ramses the Fifth 

Zafireh Paleopathntofiy Symp. 19SH 



Innovations in the study of ancient preserved man • 91 





Figure 2. Computer-generated image of mummified head. 
(Photograph courtesy of P.K. Lewin, J.K. Stevens and J. 
Trogadis) 



Figure 3. Computer-generated image of skull from mum- 
mified head. (Photograph courtesy of P.K. Lewin, J.K. Ste- 
vens and J. Trogadis) 



(Figure 4) (Lewin 1984) and from a naturally mummified 
two-year-old infant from Naples (Fomaciari and Marchetti 
1986). 

The above methods and the recent use of DNA hybridiza- 
tion techniques are being used to determine the viability of at 
least some of the genetic DNA content of ancient biological 
remains. It is possible that infectious agents are still viable, 
particularly viruses in ancient human and animal specimens 
preserved in northern areas by permafrost. 

Literature cited 

Fomaciari. G., and A. Marchetti. 1986. Intact Smallpox Vims 
Particles in an Italian Mummy of the XVI Century: An Immuno- 
Electron Microscopic Study. Paleopathology Newsletter, 56;7- 
12. 

Lewin, P.K. 1967. Palaeo-Electron Microscopy of Mummified 
Tissue. A'amre. 2I3;416-417. 

1978. Whole Body Scan of an Egyptian Mummy Using 

X-Ray Computed Axial Tomography. Abstract of a paper pre- 
sented to Paleopathology Association Meeting, April 1978. Pa- 
leopathology Newsletter. 22:T7-8. 

1984. "Mummy" Riddles Unraveled. Microscopy Society 



of Canada Bulletin. 12:4-8. 

Lewin, P.K., and DC. Harwood-Nash. 1977. X-Ray Computed 
Axial Tomography of an Egyptian Brain. International Research 
Communication System. Medical Science, 5:78. 

Stevens, J.K., and J. Trogadis. 1986. Reconstructive Three Dimen- 
sional Electron Microscopy. Analytical and Quantitative Cytol- 
ogy and Histology, 8: 102- 107. 

Za^rfb Pateopatholony Symp. 1988 




Figure 4. Smallpox-like viral particle found on the mummy 
of Ramses the Fifth (x 200,000) (Lewin 1984). 



SuiviMARV OF AUDIENCE DISCUSSION: The three-dimensional image 

generated by computcri7ed radiology is sufFicicntly accurate to be 
usable tor forensic purposes especially in cases of only partial pres- 
ervation of cranial bones. The value of preserving such images of 
bones scheduled for interment is potentially enomious. The present 
resolution of I ..S mm is expected to be reduced soon to 0.25 mm or 
even lower, which would permit evaluation of such areas as the 
pubic symphysis which are uniquely useful in paleopathology. A 
good deal of ethnic variation remains to be included into the pro- 
grams, after which it may be possible to create a reconstructed 
image of the .soft tissue on the basis of a "skull-scan." 



Harris' lines in adults: An open problem 



Lubos Vyhnanek and Milan Stloukal 



More than 30 years ago Harris drew 
attention to the characteristic meta- 
physeal transverse lines found in the 
x-ray pictures of the long bones, espe- 
cially in children. He rightly concluded 
that these lines represented the conse- 
quences of the temporary arrest of 
growth which could be caused by dif- 
ferent factors (Harris 1933). The term 
"lines" refers to the radiological pic- 
tures in reality; they constitute zones of 
lamellar bone (Figure 1) which appear 
as lines when tangentially projected in 
the x-ray picture. They develop during 
the growth of the bones as the result of a 
temporary growth mechanism distur- 
bance of cartilaginous cells and of os- 
teoblasts (Goodman et al. 1984). These 
zones can be best demonstrated in the 
long bones, although the temporary ar- 
rest of growth of course involves the 
entire skeleton (Steinbock 1976). With 
renewed growth and during its further 
course, the zones remain in place and 
appear therefore successively more and 
more distant from the epiphyseal level 
in the diaphyseal direction. They 
usually — and in some cases very 
early — undergo resorption and disap- 
pear; in other cases they remain appar- 
ent up to an advanced age (Gam and 
Schwager 1967). In tribute to the author 
who described them the lines are called 
Harris' lines. 

Even this very schematic presenta- 
tion of Harris' lines includes the fea- 
tures which it is necessary to remember 
with respect to their application in an- 
thropological research. In the first 



place, these lines never represent the 
full registration of all periods of tempo- 
rary arrest of growth. Their absence 
never means that the individual did not 
suffer from any disease or hunger 
period in his past history. The laws gov- 
erning the persistence of Harris' lines 
up to adult age are unknown. It cannot 
be assumed that the most prominent or 
most recent Harris" lines are preserved 
because clinical studies prove this is 
not so. 

A broad variety of factors provoke 
Harris' lines (Cohen and Armelagos 
1984). Harris' lines are found after in- 
flammation of the upper respiratory 
passages as well as after other infec- 
tious diseases, in diabetes, chronic ane- 
mias, chronic metal and other poison- 
ing, and after surgical interventions. 
Animal experiments demonstrated that 
they are induced by protein and vitamin 
A deficiency, and by fasting in general 
(Acheson and Maclntyre 1958). During 
long-time follow-up of children it was 
found that the number of Harris" lines 
does not necessarily equal the number 
of illness periods (Gindhart 1969). In 
some cases the lines appeared even 
without any proved cause. 

In clinical practice, Harris' lines in 
adults are not considered as clinically 
important and usually they are not men- 
tioned in interpretation of radiological 
pictures. In recent years a new interest 
in Harris' lines was raised by studies in 
which the authors tried to use them for 
paleopathological purposes (Allison et 
al. 1974). Among studies which dealt 



?y7* 




Figure 1 . Prominent Harris' lines at a 
distance of 45 mm from distal articular 
surface of tibia. Photograph of section 
of bone. 



92 



Zagreb Paieopathology Symp. 1 988 



Harris' lines in adults: An open problem • 93 



very thoroughly from different points 
of view with the incidence of Harris' 
hnes in ancient bone materials, we 
mention especially the studies of Wells 
(1961. 1967) and Kuhl (1977). Calvin 
Wells introduced the Index of Mor- 
bidity, as the means to characterize a 
population group. The best preserved 
long bone of the skeleton is always se- 
lected for study, and the number of Har- 
ris' lines in the entire population stud- 
ied is divided by the number of 
observed skeletons. Unfortunately, 
studies applying Wells' Morbidity In- 
dex do not mention if the number of 
Harris' lines counted includes only 
those which completely traverse the full 
width of the bone or those which are 
partially preserved. In our opinion, 
these incomplete remnants of Harris' 
lines signal the period of temporary 
growth arrest in the individuals past as 
importantly as the complete ones. In 
addition it is necessary to take x-ray 
pictures of the evaluated bones in two 
views; the discrete shadow of Harris' 
lines may be seen only in one projec- 
tion. 

As an example of the incidence of 
Harris' lines in a recent population we 
present the findings in a group of 160 
men with x-ray pictures of the lower 
extremities examined for other than an- 
thropological reasons in one region of 
Czechoslovakia. We followed the Har- 
ris' lines especially in the tibiae, where 
these lines appeared most prominently 
and where they could be recognized 
most securely. The average age of the 
men examined was 67.3 years, ranging 
from 49 to 88 years. With five excep- 
tions only, the childhood of all these 
men occurred during the period of 
World War I. or the years close to it. It 
could be supposed that apart from the 
usual childhood infectious diseases, 
they were exposed to other similar 
provoking factors during their growth, 
especially dietary deficiency. Never- 
theless, this study was not made to esti- 
mate the influence of different factors 



in the frequency of Harris' lines but to 
follow the Harris' lines preserved in a 
group of adult men at a certain individ- 
ual age and with a similar childhood 
history. 

In this group of 160 adult men, Har- 
ris' lines were found in only 35 (21.9%) 
cases. This would imply that nearly 
80% of these men did not sutler from 
any serious illness or hunger period 
during World War I, which is hardly 
probable. Harris' lines were bilateral in 
27 (77.1%) of the 35 men, on the right 
side only in 3 (8.6%) and on the left 
side in 5 (14.3%). The average age of 
the men with the Harris' lines was 68.5 
years (ranging from 62 to 84 years). It 
did not differ significantly from the 
average age of men without Harris' 
lines. In most cases more than two Har- 
ris' lines were present. Lines nearest to 
the epiphysis were mostly complete; 
lines situated nearer to the center of the 
bone were often represented by their 
dorsally and tibially preserved parts 
only. 

The distance of the Harris' line to the 
distal tibial articular surface was differ- 
ent in individual cases. In most cases it 
was 2.5-3.5 cm, but in several cases it 
measured 6 cm and exceptionally 10 
cm. In bilateral findings the distance on 
the right and left side was equal. Only 
in 2.8% of men — quite sporadic — was 
it possible to identify Harris' lines not 
only in the distal parts of the tibiae but 
in the proximal ends, too. In one of 
these findings the distance between the 
first proximal Harris' line and the prox- 
imal articular surface of the tibia corre- 
sponded with the distance between the 
first distal Harris" line and the distal 
tibial articular surface. In all cases of 
proximal tibial Harris' lines, distal Har- 
ris' lines were present also. In only two 
cases did Harris' lines in the distal parts 
of the fibulae accompany those in the 
tibiae. Considering the total number of 
tibiae with preserved Harris' lines, 
these two fibula ca.ses are really excep- 
tional. 



We studied the coincidence of Har- 
ris' lines and the persistence of the epi- 
physeal line in the distal end of the 
tibia. The result in our group showed 
that no less than 31 (88.6%) of the men 
with Harris' lines aged 62 to 84 also had 
preservation of the epiphyseal line at 
the same time. Only 4 men (11.4%) 
with Harris' lines failed to demonstrate 
a recognizable epiphyseal line. In men 
without Harris' lines, the epiphyseal 
line was visible in only 41 (32.8%). 
The association of simultaneous per- 
sistence of Harris' lines and of the epi- 
physeal line was statistically signifi- 
cant. 

In conclusion, we summarize our 
opinions on the possibility of using 
Harris' lines in the paleopathological 
analysis of adults: 

1 . It is necessary to consider Harris' 
lines in the skeleton of an adult individ- 
ual as an expression of a strikingly indi- 
vidual feature. The absence of Harris' 
lines can hardly represent secure evi- 
dence of the general state of health of 
the population because there are no 
identified rules of their preservation up 
to adult age. 

2. Asymmetry of the occurrence of 
Harris' lines on the left and right side of 
long bones is so exceptional that it is 
possible to use either tibia for their 
demonstration and study. 

3. In the evaluation of Harris' lines, 
it is necessary to base the result on x-ray 
pictures in two views to demonstrate 
incomplete lines. 

4. It is possible to use the frequency 
of Harris' lines to characterize a certain 
population group if it is remembered 
that Harris' lines are polyetiological 
and that the problems of their per- 
sistence up to adult age are not solved. 

5. The statistical significance of the 
coincidence of persistent Harris' lines 
with the epiphyseal lines in our group 
suggests very interesting relationships. 



Zagreb Paleopathology Symp. 1988 



94 • Lubos Vyhnanek and Milan Stloukal 



Literature cited 

Acheson, R.M.. and M.N. Maclntyre. 
1958. The Eft'cLts of Acute Infection and 
Acute Starvation on Skeletal Develop- 
ment. A Study of Young Rats. British 
Journal of Experimenial Pathology, 
39:37-45. 

Allison, M.J. . D. Mcndoza, and A. Pezzia. 
1974. A Radiographic Approach to 
Childhood Illness in Precolumbian In- 
habitants of Southern Peru. American 
Journal of Physical Anthropology. 
40:409-416. 

Cohen, M.N., and G.J. Armelagos. 1984. 
Paleopathology at the Origins of Agricul- 
ture; Hditors' Summation. In M.N. 
Cohen and G.J. Armelagos, eds.. Paleo- 
pathology at the Origins of Agriculture . 
585-601. New York: Academic Press. 

Gam, S.M., and P.M. Sch wager 1967. 
Age Dynamics of Persistent Transverse 
Lines in the Tibia. American Journal of 
Physical Anthropology. 27:315-311. 

Gindhart, P.S. 1969. The Frequency of Ap- 
pearance of Transverse Lines in the Tibia 



in Relation to Childhood Illness. Ameri- 
can Journal of Physical Anthropology. 
31:17-22. 

Goodman, A.H., D.L. Martin, and G.J. Ar- 
melagos. 1984. Indications of Stress 
from Bone and Teeth. In M.N. Cohen and 
G.J. Armelagos, eds. , Paleopathology at 
the Origins of Agriculture. 13-49. New 
York: Academic Press. 

Harris, H.A. 1933. Bone Growth in Health 
and Disease. London: Oxford University 
Press. 

Kuhl, I. 1977. Die Leichenbrande vom 
Brandgraberfeld auf der Dune Wissing. 
Gem. Halden. 213. Kiel, Germany: 
Kreis Wesel. 

Steinbock, R.T. 1976. Paleopathological 
Diagnosis and Interpretation. 46-55. 
Springfield, 111.: Charles C Thomas. 

Wells, C. 1961. A New Approach to An- 
cient Disease. Discovery. 22:526-531. 

1967. A New Approach to Paleo- 
pathology: Harris' Lines. In D. Brothwell 
and A.T. Sandison, eds. , Diseases of An- 
tiquity. 390-404. Springfield, 111.: 
Charles C Thomas. 



Summary of audience discussion: The 
"disappearance" of Harris' lines in adults 
may be an illusion, resulting from their 
obscuration by the thickening of the grow- 
ing diaphyseal cortex; they may become 
apparent again ("reappear") following 
demineralization of the bone in the os- 
teoporotic patient. It is also important to 
remember that only those who sufler a tran- 
sient pulse of illness and recover promptly 
will develop them; the chronically ill and 
the very healthy individuals do not develop 
Harris' lines. Correlation between develop- 
ment of Harris' lines and dental hypoplasia 
is often not high because each responds to 
different stimuli or at least to different de- 
grees, but if one compares all microscopic 
dental defects the correlation is good. 



Zagret> Paleopalhotogy Symp. lV<'i8 



Medical ceramic representation of nasal 

leishmaniasis and surgical amputation 

in ancient Peruvian civilization 

Oscar Urteaga-Ballon 



From 3000 years ago until the Spanish 
conquest, the central part ot the mighty 
Andean Mountains of South America 
was the center of some of the most 
splendid, ancient American civiliza- 
tions. The Inca empire was the last of 
those civilizations. It began in the Peru- 
vian lands and spread throughout parts 
of Ecuador, Colombia. Bolivia, Argen- 
tina and Chile (Larco-Hoyle 1938- 
1939; Mason 1957; Tello and Mejia 
1960; Bird 1962; Sawyer 1966). The 
Incas considered themselves the direct 
descendants of the sun and moon, 
which they worshipped as their gods. 
The ancient Peruvians did not leave a 
written language, but in their metal art, 
pottery and textiles, they did leave a 
graphic sculptural language, which, if 
one is prepared to do so, can be read 
like the pages of a book. In the north 
coast valleys of Peru began one of the 
most splendid civilizations of ancient 
Peruvians. The Mochica culture had 
left beautiful, realistic ceramic sculp- 
tures, which covered broad aspects of 
Mochica life, including special medical 
collections. In 1968 we published a 
complete review of some chapters of 
the sexual behavior of ancient Peru- 
vians as shown in their ceramic art 
(Urteaga-Ballon 1968). These ancient 
people were [wwerful warriors with 
large conquering armies, but during pe- 
riods of peace they dcveU)pcd an out- 



standing civilization rich in artistic cul- 
ture. 

Much of what we know about the 
remarkable medical history of pre- 
Columbian Peru is the result of research 
on the ceramic pieces of the ancient 
Peruvian civilizations. Many infectious 
diseases have been portrayed in 
ceramic art. As a result of chronic war- 
fare, many people suffered serious le- 
sions which demanded different types 
of surgical operations. Mutilation and 
amputation of the limbs were frequent. 
The most dramatic representations of 
the medical pottery are the cranial oper- 
ations (trephination), which were con- 
ducted by members of the Paracas civil- 
ization beginning more than 2000 years 
ago. 

Two different types of ceramic medi- 
cal art serve to illustrate this rich and 
important source of information on an- 
cient medical traditions in the New 
World. We first present some examples 
of ceramic art showing evidence of 
leishmaniasis, a condition well known 
in modem Peru and often seen by me 
during my career as a pathologist in 
Peru. We follow this with a brief review 
of a few cases of ceramic art exhibiting 
amputated limbs and the prosthetic de- 
vices that were often made to assist the 
patient with at least some use of the 
limb following healing of the amputa- 
tion stump. 



Nasal leishmaniasis 

Mucocutaneous leishmaniasis is a 
chronic infectious disease caused by 
the protozoan Leishmania hraziliensis. 
The disease was endemic in the ancient 
Peruvian lands, as it is found in the 
ceramics of those cultures. 

Between 1 962 and 1 974 in the Muse- 
um of Paleopathology of Lima, Peru, I 
studied 67 ceramic pieces in which the 
pre-Columbian Peruvian craftsmen 
represented different lesions of infec- 
tious and parasitic diseases. In this pa- 
per I show four ceramic representations 
of mucocutaneous leishmaniasis repre- 
senting different stages of lesions af- 
fecting the nasal and oral cavities. As a 
comparative reference I include two 
other paleopathological ceramic repre- 
sentations which prove the skill and 
knowledge of the ancient Peruvian phy- 
sicians. 

Figure 1 corresponds to the famous 
portrait-head vessel of the Mochica 
ceramic described by Larco-Hoyle 
(1938-1939) and Sawyer (1966). It 
represents a congenital cleft of the up- 
per palate and lip. Figure 2 represents a 
punitive case with surgical mutilation 
of the nose and lips. Both pieces are 
examples of the graphic realism of the 
ancient Peruvian craftsmen. 

Figure 3 is also a Mochica portrait- 
head ves.sel which shows the first stage 



Zagreb Paleopathology Symp I9H8 



95 



96 • Oscar Urteaga-Ballon 



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Figure 1 . Ceramic representation of a case of cleft palate and lip. Peruvian Mochica 
culture. Lima, Peru. 

Figure 2. Ceramic representation of a punitive mutilation of nose and lips. Peruvian 
Mochica culture. Lima, Peru. 

Figure 3. Ceramic representation of a mucocutaneous leishmaniasis. Mochica 
portrait-head vessel shows an ulcerative lesion of left wall of nose. Peruvian 
Mochica culture. Lima, Peru. 

Figure 4. Ceramic representation of a case of mucocutaneous leishmaniasis. Sec- 
ond stage. Necrotic lesions have destroyed both sides of nose and upper lip. Peru- 
vian Mochica culture. Lima, Peru. 



of mucocutaneous leishmaniasis. A 
large ulcer has destroyed the left wall of 
the nose. This is a typical lesion of the 
disease. Figure 4 corresponds to an ad- 
vanced stage of the infection. The ne- 
crotic lesions have destroyed both sides 
of the nares walls and the infection has 
also invaded the left side of the upper 
lip. If you compare the graphic repre- 
sentations of these four cases you can- 
not miss the diagnosis. In our time the 
microscopic finding of the protozoan 
organism makes the diagnosis defini- 
tive, but the gross lesion is extremely 
clear in the endemic zones of this dis- 
ease. Figure 5 corresponds to the third 
stage of the leishmaniasis infection. 
The necrotic lesion has destroyed not 
only the subcutaneous tissues of the 
nose, but also completely destroyed the 
nasal septum, rounding and widening 
the nasal cavity. The upper lip has also 
disappeared but there are no lesions in 
the dental alveolar process. 

The last stage of the disease is 
characterized by a complete destruction 
of the nasal cavity with partial resorp- 
tion of the hard palate bone, which pro- 
duced a direct opening between the 
nasal and the oral cavities. Figure 6 
shows one of these cases. The destruc- 
tion of the frontal part of the palate bone 
also produces the loss of the upper in- 
cisor teeth. 

We have found similar lesions in the 
skull of some ancient Peruvian mum- 
mies. Figure 7 corresponds to one of 
these skulls and shows a complete de- 
struction of the nasal septum and the 
resorption of the lateral border lines of 
the nasal cavity, which appear un- 
usually round and wide. The bone re- 
sorption also included the anterior part 
of the palate bone. Figure 8 corre- 
sponds to a Mochica ceramic which 
represents the frontal view of the face of 
a normal skull. The Peruvian craftsmen 
have represented the anatomical pro- 
portion of size and shape of the nasal 
and oral cavities, including the nasal 
septal bone. 



Zagreb PulfofHiihitlof;}' Symp. 1988 



Nasal leishmaniasis and amputation in ancient Peruvian ceramics • 97 



Some paleopathologists have de- 
scribed these nasal and oral lesions as 
pathognomonic of a form of leprosy. 
Ortner and Putschar (1981). in their 
classic paleopathology book, have 
commented on the findings of different 
investigators in skulls found in a medi- 
eval Danish leprosy cemetery in 1953. 
All of them think that these nasal and 
oral lesions are characteristic of lep- 
rosy. However, they did not discard the 
pt>ssibility that similar lesions could be 
found in tertiary syphilis and in lupus 
vulgaris. 

My experience in more than thirty 
years as a pathologist of tropical infec- 
tious diseases is different. Today, in the 
jungle of the Amazon River, leprosy is 
endemic. We have seen more than 300 
patients with leprosy there. Many of 
them were in the acute lepromatous 
stage and others had chronic, advanced 
lesions. Most of those patients had mi- 
croconfluent, nodular lesions of the 
nose. Some of them also had gran- 
ulomatous lesions in the nasal septum 
with ulceration and perforation of the 
septum, but we did not find one case in 
which the nasal septum and the palate 
bone were totally destroyed giving the 
classic appearance of a round, wide and 
large nasal cavity with nasal-oral com- 
munication. 

However, in the jungle of the Ama- 
zon River, mucocutaneous leishmania- 
sis is also endemic. We have studied 
almost 100 cases of these patients. 
More than 20 were in an advanced 
stage, showing the typical destructive 
lesions of the nasal septum and the pal- 
ate bones, exactly like the graphic rep- 
resentations in the ceramics of the an- 
cient Peruvians. 

Mitsuda and Ogawa (1937) reviewed 
150 autopsies in the Aisein National 
Leprosarium in Japan. On this subject 
they said. "Some leprotic periostitis 
and involvement of the osseous struc- 
ture are found in various bones, such as 
the tibia and the phalanges." However, 
they did not describe any special naso- 




FiGURE 5. Ceramic representation of a case of mucocutaneous leishmaniasis. Third 
stage. Infection has destroyed nasal septum, rounding and widening nasal cavity. 
Peruvian Mochica culture. Lima, Peru. 

Figure 6. Ceramic representation of a case of mucocutaneous leishmaniasis. Last 
stage. Complete destruction of nasal cavity with partial resorption of hard palate 
bone. Peruvian Mochica culture. Lima, Peru. 

Figure 7. Ancient Peruvian skull with a case of mucocutaneous leishmaniasis, 
showing classical nasal and oral lesions of this disease. Nose is round and wide for 
total destruction of nasal bones. Part of palate bone also destroyed. Skull of Peru- 
vian mummy. Lima, Peru. 

Figure 8. Ceramic representation of face of a normal skull showing anatomical 
proportion of size and shape of nasal and oral cavities, including septum. Peruvian 
Mochica culture. Lima, Peru. 



Zagreb Paleopathology Symp. 1988 



98 • Oscar Urteaga-Ballon 



oral destructive lesions. Kean and 
Childrees (1942) made a summary of 
103 autopsies of leprosy cases at the 
Gorgas Hospital, Canal Zone, Panama. 
They described the leprosy osseous le- 
sions as follows: "Amputation of one 
toe 12, one or more fingers 14, leg 9, 
foot 1; absorptions of fingers 19, toes 
18, feet 3; gangrene of the toe 2, mis- 
cellaneous lesions 7." They also did not 
find the naso-oral destructive lesions. 
Desikan and Job ( 1968) in the General 
Hospital in Vellore, India, reviewed 37 
autopsies of leprosy. They did not de- 
scribe one case of naso-oral destructive 
lesions. 

Enna (1968), in Ryukyu Island in 
Okinawa, studied 996 leprosy patients 
with lesions showing advanced defor- 
mity; 15.2% had nasal deformities, but 
not one had the osseous destruction of 
the oral and nasal cavities. Bernard and 
Vazquez (1973) studied 60 necropsies 
with similar results. 

However, other leprologists have 
found some degree of destructive le- 
sions in the nasal cavity of leprosy pa- 
tients. Powell and Swan ( 1955), in the 
National Leprosarium at Carville, 
Louisiana, in advanced cases of lep- 
romatous leprosy found that ulceration 
and perforation of the nasal septum 
were common, with destruction of 
nasal cartilage and bone resulting in 
varying degrees of "saddle" deformity. 
Kumar et al. (1979), in the Leprosy 
Clinic in Chandigarh, India, described 
25 selected patients. Of these 88% had 
nasal obstruction, while 48% and 32% 
had ulceration and perforation of nasal 
septum. Barton et al. (1982), in the 
Victoria Hospital in Dichpalli, India, 
studied 62 patients of lepromatous lep- 
rosy; one of them showed a completely 
perforated septum. 

Furthermore, in a North American 
textbook of pathology, Marcial Rojas 
and Kissane ( 1985) made more radical 
affirmations. They said that mucocuta- 
neous leishmaniasis produces "exten- 
sive destruction of the soft and underly- 




FiGURE 9. Mucocutaneous leishmania- 
sis. Total destruction of septum and de- 
formation of nose and lips. Photo from 
Atlas of Tropical Pathology (Binford 
and Connor 1976:207). 



ing hard tissues of the nose and pharynx 
producing severe mutilation of the 
face." 

Finally, Binford and Connor (1976) 
make the most complete revision of lep- 
rosy and leishmaniasis. In Section 6 of 
this atlas, Binford and Meyers pub- 
lished 76 photographs of gross and mi- 
croscopic lesions of all types of leprosy. 
Despite the fact that some of their cases 
show tremendous deformation of the 
nose and the lips, none of these patients 
show the destructive bone lesions in 
their nasal-oral cavities. However, in 
Section 7 of the same atlas Connor and 
Neafie show one case of mucocutane- 
ous leishmaniasis with tremendous de- 
structive lesions. The authors say, "A 
Brazilian with mucocutaneous leish- 
maniasis has a destroyed nasal septum 
and deformed nose and lips" (F-3-B-6, 
page 261). 

We have included as comparison two 
figures from this atlas. Figure 9 shows a 
case of mucocutaneous leishmaniasis 
with a massive destruction of the nasal 
septum and deformities of the nose and 
lip. Figure 10 corresponds to a case of 
lepromatous leprosy with tremendous 



10 




Figure 10. Lepromatous leprosy. Tre- 
mendous deformation of nose and lips, 
without destruction of nasal septum, in 
contrast to case of leishmaniasis in 
Figure 9. Photo from Atlas of Trop- 
ical Pathology (Binford and Connor 
1976:261). 



deformation of the nose and the lips, 
but with no destruction of nasal-oral 
bones. 

In medicine nothing is exact; we can- 
not say with certainty that the gran- 
ulomatous nasal-oral destruction is 
pathognomonic of one specific disease. 
According to its ancient and modem in- 
cidence, mucocutaneous leishmaniasis 
occupied first place. Lepromatous lep- 
rosy is in second place. Tertiary syph- 
ilis and yaws are in third place. Rhi- 
noscleroma and other infectious 
diseases rarely produce this anatomical 
lesion. 

More important in this academic, 
historical discussion is the fact that an- 
cient Peruvian physicians had left in- 
disputable evidence of their knowledge 
of some of the most complex chapters 
of medicine. Their graphic ceramic 
representations are unquestionable. 

Surgical amputation and limb 
prostheses 

We have studied 65 ceramic pieces in 
which the Mochica craftsmen repre- 
sented traumatic medical surgery. 



Zagreb Palenpalhftto^y S\mp t9HH 



Nasal leishmaniasis and amputation in ancient Peruvian ceramics • 99 



Among them were prostheses of the up- 
per and lower extremities. We selected 
12 of these cases, the first 4 represent- 
ing different types of limb amputations 
and the rest being a complete sequence 
of the prostheses operations. 

Figure 1 1 represents a case of an am- 
putation of the left arm. The person 
uses a short cape which had a false hand 
at the bottom. Figure 1 2 shows a case of 
a bilateral arm amputation. Figure 13 
reveals an extensive operation with the 
removal of the complete right arm. A 
more radical surgical operation appears 
in Figure 14: the patient has suffered 
bilateral arm and foot amputations; it is 
possible that these surgical mutilations 
were done as a punitive sentence be- 
cause there are also mutilations of the 
upper lips and part of the wall of the 
nose. 

In the next eight ceramic pieces the 
craftsmen represent a successful se- 
quence of a prosthesis of the leg and 
arm. Figure 15 shows the traumatolo- 
gist examining a patient's leg previous 
to the operation. Figure 16 demon- 
strates the second stage. The patient has 
been operated upon recently. The two 
bones of the left leg appear through the 
surgical wound. Figure 17 shows an- 
other patient who has been operated on 
some time ago. The wound appears 
completely healed. Figures 18 and 19 
correspond to the fourth stage of the 
prosthesis operation. Two patients are 
testing the prosthesis apparatus with the 
hand opposite to the amputated leg. In 
Figure 20 another patient appears with 
the prosthesis attached to his left leg, 
and Figure 21 reveals the last stage of 
this traumatologic operation. The pa- 
tient is walking with the help of a cane 
and the prosthesis is attached to his left 
leg. 

We did not find a complete sequence 
of the prosthesis of the arms. However, 
we found two instances of patients with 
the prosthesis attached to the arms. Fig- 
ure 22 shows one of these cases. The 
patient was a blind man who had a pros- 




FiGURE 1 1 . Amputation of left arm. Mochica culture, ceramic. Lima. Peru. 

Figure 12. Bilateral arm amputation. Mochica culture, ceramic. Lima. Peru. 

Figure 13. Extensive surgical operation of right arm. Mochica culture, ceramic. 
Lima, Peru. 

Figure 14. Bilateral arm and foot amputations. Mochica culture, ceramic. Lima, 
Peru. 



Zagreb Paleopathology Symp. 1988 



100 • Oscar Urteaga-Ballon 




Figure 15. Prosthesis of the leg. Traumatologist examining patient's leg previous to 
operation. Chimu culture, ceramic. Lima, Peru. 

Figure 16. Prosthesis of the leg. Second stage. Patient has been operated upon 
recently. Two bones of left leg appear through surgical wound. Mochica culture, 
ceramic. Lima, Peru. 

Figure 17. Prosthesis of the leg. Third stage. Wound appears completely healed. 
Mochica culture, ceramic. Lima, Peru. 

Figure 18. Prosthesis of the leg. Fourth stage. Patient is testing prosthesis apparatus 
with hand opposite to amputated leg. Mochica culture, ceramic. Lima, Peru. 



thesis attached to his right arm. Nine 
ceramic pieces of the same Mochica 
culture represent some prosthesis appa- 
ratus. They correspond to the legs, 
arms and hands. One of these pieces 
represents a surgical knife held be- 
tween the fingers. The surgical knife 
was named "tumi" and the surgeons 
used it in different types of operations. 
Some ceramic pieces represent the sur- 
geons with the tumi knife in their hand 
during a cranial trephine. 

The representations of lesions and 
prostheses, carved in Peruvian 
ceramics more than 2000 years ago, are 
graphic medical lessons proving the 
knowledge and skill of pre-Columbian 
physicians. These ceramic sculptures 
illustrate an important chapter in the 
history of medicine. 

Literature cited 

Barton, R., J. Rees, C. McDougall, andG. 
Ellard. 1982. The Nose in Lepromatous 
Leprosy: Bacteriological and Histo- 
pathological Studies of Patients Treated 
with Dapsone Monotherapy. Internation- 
al Journal of Leprosy. 50:58-67. 

Bernard, J.C., and C.A. Vazquez. 1973. 
Study of Sixty Necropsies. International 
Journal of Leprosy, 4 1 :94- 101. 

Binford, C. . and D. Connors. 1976. Pathol- 
ogy of Tropical and Extraordinary Dis- 
eases. Washington, D.C.: Armed Forces 
Institute of Pathology. 

Bird J.B. 1962. Art and Life in Ancient 
Peru. An Exhibition in Curator II, New 
York. 

Desikan, K.V..andC.K. Job. 1968. A Re- 
view of Postmortem Findings in 37 Cases 
of Leprosy. International Journal of Lep- 
rosy. 36:32-44. 

Enna.C.D. 1968. A Survey of Leprous De- 
formities in Ryukyu Island. International 
Journal of Leprosy. 36:271-281. 

Kean, B.H., and M.E. Childrees. 1942. A 
Summary of 103 Autopsies of Leprosy 
Patients on the Isthmus of Panama. Inter- 
national Journal of Leprosy. 10:51-59. 



Zagreb Paleopathotofiy Symp. 1988 



Nasal leishmaniasis and amputation in ancient Peruvian ceramics • 101 



Kumar, S.. K. Malik, B. Kuman, M. 
Singh, and R. Chakravarty. 1979. Respi- 
ratory System Involvement in Leprosy. 
InternalionalJournal of Leprosy. 47: IS- 
IS. 

Larco-Hoyle. R. 1938-1939. Los Mochi- 
cas. Lima, Peru. 

Mareial Rojas. R.A.. and J.M. Kissane. 
1985. Mucocutaneous Leishmaniasis. In 
J.M. Kissane, ed.. Anderson's Pathol- 
ogy, 411-412. St. Louis: C.V. Mosby. 

Mason. J. A. 1957. The Ancient Civilization 
of Peru. IHamiondsworth. Middlesex): 
Penguin Books. 

Milsuda. K., and M. Ogawa. 1937. A 
Study of One Hundred and Fifty Autop- 
sies on Cases of Leprosy. International 
Journal of Leprosy. 5:53-60. 

Ortner. D.J.. and W.J.G. Putschar 1981. 
Identification of Pathological Conditions 
in Human Skeletal Remains. Smithso- 
nian Contributions to Anthropology, 
28:176-180. Washington, DC: Smith- 
sonian Institution Press. 

Powell, S.C, and L.L. Swan. 1955. Lep- 
rosy: Pathologic Changes Observed in 
Fifty Consecutive Necropsies. American 
Journal of Pathology. 31:1131-1148. 

Sawyer, A.R. 1966. Ancient Peruvian 
Ceramics. The Nathan Cummings Col- 
lection. New York: The Metropolitan 
Museum of Art. 

Tello, J.C. and X.T. Mejia. 1960. Chavin. 
Cultura Matriz de al Civilizacion And- 
ina. Lima, Peru: Imprenta de la Univer- 
sidad de San Marcos. 

Urteaga-Ballon, O. 1968. Interpretation of 
Se.xuality in the Ceramic Art of Ancient 
Peru. Lima. Peru: Museo de Pal- 
eopatologia. Hospital "2 de Mayo." 




Figure 19. Prosthesis of the leg. Fourth stage. Patient is testing prosthesis apparatus 
with hand opposite to amputated leg. Mochica culture, ceramic. Lima. Peru. 

Figure 20. Prosthesis of the leg. Fifth stage. Prosthesis apparatus attached to 
patient's left leg. Mochica culture, ceramic. Lima, Peru. 

Figure 21 . Prosthesis of the leg. Last stage. Patient is walking with help of a cane 
and prosthesis is attached to his left leg. Mochica culture, ceramic. Lima, Peru. 

Figure 22. Prosthesis of right arm. Patient was a blind man who had a prosthesis 
attached to his right arm. Mochica culture, ceramic. Lima, Peru. 



Zagreb Paleopathology Symp. 1988 



Population Studies 



Temporal variation in femoral cortical thickness 
of North American Plains Indians 



Douglas W. Owsley 



Oortical bone growth during periods 
of juvenile gain and later adult loss has 
been documented in long-term studies 
of populations in Central and North 
America (Gam 1970). Several vari- 
ables aft'ect tubular bone cortical thick- 
ness including age, sex, and nutrition. 
Changes in the bone envelope are 
surface-specific and reflect the com- 
bined response of subperiosteal apposi- 
tion and endosteal resorption or apposi- 
tion. 

Simple malnutrition slows the rate of 
bone growth and can lead to the forma- 
tion of less bone (Gam 1970,1972). 
Subperiosteal growth depends more on 
caloric sufficiency, protein seems to be 
less of a limiting nutrient. The effect of 
protein-energy malnutrition on cortical 
thickness is seen primarily on the inner 
bone surface. Endosteal resorption in- 
duced by kwashiorkor or marasmus can 
reduce the cortical wall to a thin shell 
with an enlarged medullary cavity. As 
much as 40% of the preformed bone 
can be lost, even though the external 
bone size remains relatively unaffected 
(Gam 1970; Gam et al. 1964,1969). 
Recovery-related catch-up growth or 
surface repair through endosteal re- 
placement is limited (Gam 1966). 

Although most studies of cortical 
bone mass have focused on the living, 
these observations can be applied to the 
analysis of archeological samples. Bio- 
archeological interpretations of past 
subsistence patterns have used cortical 
bone growth and thickness as an indica- 
tor of nutritional status (Cashion 1987; 
C(X)k 1979; Huss-Ashmore 1978; 

Zagreb Paleopathology Symp. 1*^88 



Hummert 1983; Hummert and Van 
Gerven 1983; Keith 1981; Owsley 
1985). Cashion (1987) and Owsley 
(1985) have reported age-controlled 
adult femoral midshaft cortical thick- 
nesses in temporally sequential North 
American Arikara Indians of South 
Dakota. Comparison of bone cortex 
data for villagers representing three ar- 
cheological variants of the Plains Vil- 
lage Coalescent Tradition (Extended. 
A.D. 1550-1675; Post-Contact, a.d. 
1675-1780; and Disorganized, a.d. 
1780-1845) revealed statistically sig- 
nificant differences. Relative to the ear- 
lier Extended Coalescent and later Dis- 
organized Coalescent samples, the 
Post-Contact Variant sample showed 
more cortical bone, presumably reflect- 
ing greater success in meeting village 
nutritional needs. 

This presentation examines the his- 
torical patterning of these temporal dif- 
ferences. Specific objectives are to de- 
fine the surface-specific nature of the 
differences reported between archeo- 
logical variants and to apply greater 
temporal control using chronological 
periods of shorter duration. Cortical 
thickness is a composite measure deter- 
mined by both the medullary cavity and 
the total subperiosteal diameters. Are 
changes in cortical thickness caused by 
changes in only one or both of these 
dimensions? Greater temporal control 
was made possible by obtaining data 
for related sites and by sorting this 
larger data base into smaller temporal 
units representing Late Prehistoric 
(A.D. 1600-1650), Eariy Protohistoric 



(1650-1740), Late Protohistoric 
(1740-1795), and Historic (1795- 
1832) period sites. Comparison of 
these four samples provides a clearer 
representation as to the timing of corti- 
cal bone change during the Post- 
Contact period. An appreciation of this 
timing is essential for understanding 
the nutritional impact of contact-related 
historical events. 

Materials and methods 

Sample sizes and approximate dates of 
the 12 archeological sites included in 
this analysis are presented in Table 1 . In 
order to avoid age-related cortical bone 
involution, the analysis was limited to 
femora of young adults aged 16-35 
years, giving a total of 1 10 males and 
134 females. The bones were x-rayed 
in a standardized posterior-anterior pro- 
jection using a Kodak single lanex, fine 
screen X-omatic cassette. Only bones 
in good condition were measured with 
preference given the left side when 
available. 

Two midpoint cross-sectional obser- 
vations, total subperiosteal diameter 
(T) and width of the medullary cavity 
(M), were measured with a Helios dial 
caliper to 0.1 mm (cf. Gam 1970). 
Three composite variables were de- 
rived from these measurements: corti- 
cal thickness (C), Nordin's Index (NI), 
and cortical area (CA). Cortical thick- 
ness was calculated as C = T — M. The 
value C represents the combined or net 
thickness of the medial and lateral 
walls. Nordin's Index (NI) or score was 

105 



106 • Douglas W. Owsley 



determined as Nl = C/T. This score is 
essentially two-dimensional and de- 
scribes the proportion of the total width 
attributed to the cortex. Cross-sectional 
area measurements were calculated as 
CA = 0.785 {T- - M=) (Gam 1970). 
This procedure assumes that the femur 
has an approximately circular cross- 
sectional geometry in both the endo- 
steal and subperiosteal surfaces. The 
assumption of a cylindrical shape is not 
necessarily valid for the femur (Van 
Gerven et al. 1969). Nevertheless, it is 
useful to consider cortical area as an- 
other indicator of bone status because 
this value represents absolute bone 
mass and potential calcium reserves (J. 
Dequeker, pers. comm.). As judged 
from studies based on the second meta- 
carpal, cortical area shows the highest 
correlation with the ash content of the 
bone relative to the other measurements 
and indices (Dequeker 1976). Max- 
imum femoral lengths (ML) were mea- 
sured on the radiographs using a metric 
ruler. Sample differences were evalu- 
ated using the general linear models 
analysis of variance statistic presented 
inSAS(1985). 



Results 

Sample means and standard deviations 
are presented in Table 2 by sex for each 
of the four time periods. The means for 
cortical thickness and Nordin's Index 
are illustrated in Figures 1 and 2. Re- 
sults of the analysis of variance com- 
parisons by sex and time period are 



given in Table 3. As expected, sex dif- 
ferences are highly significant for the 
three primary variables (i.e., M, T, 
ML) and also for cortical thickness and 
area, but not for Nordin's Index. Tem- 
poral differences are evident in each 
variable with the exception of max- 
imum length. The femoral lengths of 
these four samples are similar. In con- 



Table 1. Archaeological sites, sample sizes and time periods 



Site 


Site 




N 


Dale range 


Time period 




number 


Males 


Females 








Leavenworth 


39C09 


13 


13 


1802- 


1832 


Historic 


Leavitt 


39ST215 


3 


1 


1784- 


1792 


Late Protohistoric 


Cheyenne River 


39ST1 


1 


1 


1740- 


. 1795 


Late Protohistoric 


Stony Point Village 


39ST235 


3 


6 


1740- 


• 1795 


Late Protohistoric 


Four Bear 


39DW2 


3 


10 


1758- 


■ 1774 


Late Protohistoric 


Dinehart Villae 


39LM33 


6 


2 


1725- 


• 1760? 


Early Protohistoric 


Larson 


39WW2 


24 


34 


1679- 


• 1733 


Early Protohistoric 


Oahe Village 


39HU2 


6 


1 


1650 


• 1725 


Early Protohistoric 


Swan Creek 


39WW7 


15 


7 


1675 


■ 1725 


Early Protohistoric 


Sully 


39SU 


14 


20 


1650 


■ 1733 


Early Protohistoric 


Mobridge 2 


39WW1 


11 


24 


1675 


- 1700 


Early Protohistoric 


Mobridge L 3 


39WW1 


7 


7 


1600 


- 1650 


Late Prehistoric 


Rygh 


39CA4 


4 


8 


1600 


- 1650 


Late Prehistoric 



Table 2. Means and standard deviations for femoral cortex and maximum length measurements by sex and 
time period 





Late Prehistoric 


Early Protohistoric 


Late Protohistoric 




Historic 




Variable 


N 


Mean 


S.D. 


N 


Mean 


S.D. 


N 


Mean 


S.D. 


N 


Mean 


S.D. 


MALE 


























M 




11.79 


1.37 


76 


12.24 


1.92 


10 


13.50 


2.20 


13 


13.42 


1.95 


T 




25.29 


2.12 


76 


26.94 


1.55 


10 


28.09 


1.20 


13 


27.64 


1.51 


C 




13.5 


2.15 


76 


14.69 


1.55 


10 


14.59 


1.67 


13 


14.22 


2.04 


NI 




0.53 


0.06 


76 


0.55 


0.06 


10 


0.52 


0.07 


13 


0.51 


0.06 


CA 




394.84 


79.92 


76 


450.94 


51.85 


10 


473.92 


44.18 


13 


457.27 


63.98 


ML 


8 


466.13 


13.93 


66 


466.85 


22.22 


9 


481.22 


20.21 


12 


470.75 


24.07 


FEMALE 


























M 


15 


11.44 


1.68 


88 


10.57 


1.60 


18 


11.58 


2.10 


13 


12.95 


1.53 


T 


15 


24.01 


2.32 


88 


24.12 


1.54 


18 


24.84 


1.94 


13 


25.00 


1.32 


C 


15 


12.57 


1.38 


88 


13.55 


1.51 


18 


13.26 


1.95 


13 


12.03 


1.62 


Nl 


15 


0.52 


0.04 


88 


0.56 


0.06 


18 


0.53 


0.07 


13 


0.48 


0.06 


CA 


15 


351.79 


62.59 


88 


368.76 


49.07 


18 


378.51 


64.17 


13 


358.17 


51.08 


ML 


12 


431.83 


21.77 


76 


429.47 


17.01 


17 


431.71 


17.34 


11 


433.45 


18.69 



a. M, medullary cavity diameter; T, total subperiosteal diameter; C, cortical thickness; NI, Nordin's index; CA, 
cortical area; ML, maximum length. 



Zagreb Palenpathoipgy Symp. I98fl 



Femoral cortical thickness of North American Plains Indians • 107 



trast, marked sample differences are 
present in the amounts of cortical bone, 
as measured by the variables C. Nl and 
CA. The separate patterns reflected by 
male and female measurements reveal 
marked correspondence. Mean values 
for C and Nl for the Early Protohistoric 
period represent the high peaks for this 
time series. Cortical thickness in- 
creased in both sexes during the transi- 
tion from the Late Prehistoric to the 
Early Protohistoric period. These 
gains, however, were only temporary 
and not sustained in the more recent 
time periods. Later samples have re- 
duced cortical thicknesses. Both sexes 
correspond in this trend, although 
females reveal the most dramatic loss of 
tubular bone. 

Sample differences in C and Nl re- 
flect net changes in both the medullary 
cavity diameter and the total sub- 
periosteal diameter. In females, me- 
dullary widths decreased during the 
Early Protohistoric period. Late Pro- 
tohistoric and Historic period female 
values returned to the Late Prehistoric 
average diameter and then greatly sur- 
passed this base, more closely approx- 
imating the larger diameters of males. 
Males during the Late Protohistoric and 
Historic periods are characterized by 
larger medullary cavity diameters than 
found decades earlier in Arikara popu- 
lations. Total subperiosteal diameters 
also show temporal change with mean 
values for T increasing through time, 
especially in males. In terms of estimat- 
ed cortical areas, these small increases 
in T diminish the effect of the linear 
increases in M, the smaller diameter. In 
both sexes, calculated cortical areas 
show the largest increase with the tran- 
sition from the Late Prehistoric to the 
Early Protohistoric period. Because of 
the increase in T, cortical areas con- 
tinue to increase through the Late Pro- 
tohistoric period, followed by decline 
during the early Historic period. In the 
most recent period, male and female 
cortical areas, although approaching 
the early 17th century base line (espe- 
cially in females) are still higher than 
during the Late Prehistoric Period. 



1500- - 



I4O0-. 



liOO-. 



1200.. 
mm 



FEMALES 
•MALES 



LATE 
PREHISTORIC 



EARLY 
PROTOHISTORIC 



LATE 
PRerOHISTORIC 



HISTORIC 



Figure I . Femur midshaft cortical thickness by time period 



0.57 . 



0.56 



055 .. 



Q54 .. 



0.53 .. 



0.52 . 



Oil .. 



050 ■■ 



0.49 .. 



0.48 



0.47 



Nl 



FEMALES 



MALES 



-I- 



LATE 
PREHISTORIC 



EARLY 
PROTOHISTORIC 



LATE 
PROTOHISTORIC 



HISTORIC 



Figure 2. Temporal variation in Nordin's Index 



Zagreb Paleopathology Symp. 1988 



108 • Douglas W. Owsley 



Table 3. Two-factor analysis of variance of femur 
measurements by time period and sex 



Variable Souxe 



DF 



M 



NI 



CA 



ML 



Sum of 
squares 



PR>F 



Model 

Time 

Sex 

Interaction 

Error 

TOTAL 

Model 

Time 

Sex 

Interaction 

Error 

TOTAL 



TOTAL 

Model 

Time 

Sex 

Interaction 

Error 

TOTAL 

Model 

Time 

Sex 

Interaction 

Error 

TOTAL 

Model 

Time 

Sex 

Interaction 

Error 

TOTAL 



7 
3 
1 
3 
236 

243 

7 
3 
1 
3 
236 

243 



Model 7 

Time 3 

Sex 1 

Interaction 3 

Error 236 



243 

7 
3 
1 
3 
236 

243 

7 
3 
1 
3 
236 



7 
3 
1 
3 
203 

210 



226.61 
89.81 
39.04 
17.49 

748.57 

975.18 

495.64 
56.23 

202.78 
15.35 

632.76 

1128.40 

144.62 

42.25 

63.87 

6.89 

622.45 

767.07 

0.11 
0.09 
0.00 
0.02 
0.80 

0.91 

443280.83 
39578.65 

207997.53 
12656.08 

697817.91 



243 1141098.74 



78253.13 

1552.64 

43241.22 

852.13 

78320.04 

156573.17 



10.21 
9.44 

12.31 
1.84 



26.41 
6.99 

75.63 
1.91 



7.83 

5.34 

24.21 

0.87 



4.48 
8.43 
0.08 
1.49 



21.42 
4.46 

70.34 
1.43 



28.98 

1.34 

112.08 

0.74 



0.0001 
0.0001 
0.0005 
0.14 



0.0001 
0.0002 
0.0001 
0.13 



0.0001 
0.001 
0.0001 
0.46 



0.0001 
0.0001 
0.78 
0.22 



0.0001 
0.0045 
0.0001 
0.24 



0.0001 
0.26 
0.0001 
0.53 



NOTE: Sums of squares for time period, sex and interaction are 
Type III. For variable abbreviations see Table 2. 



The interpretation of the overall pat- 
terns revealed by the variables C and NI 
and CA offers insight into the nutrition- 
al status of the post-contact Arikara. 
Specific reference to the archeological 
and ethnohistorical records helps 
clarify the historical events that affected 
food resources and reserves. 

Discussion 

The period after Euro-American con- 
tact was one of dramatic change. 
Arikara villages were located along the 
flood plain and lower terraces of the 
Missouri River valley (Lehmer 1971). 
Their mixed subsistence strategy was 
based on the gathering of wild plants, 
the cultivating of com. beans, squash, 
and sunflowers, trading, and hunting, 
especially of bison. Initially, their war- 
riors controlled activities on the river. 
Because of their ideal geographic loca- 
tion, the villagers actively participated 
in intertribal exchange networks, reap- 
ing profits as middlemen between 
groups bringing aboriginal and Euro- 
pean trade materials from the eastern 
woodlands and others in the southern 
Plains and the southwest (Ewers 1955; 
Orser 1984; Wood 1980). This trade 
network had its roots in the Prehistoric 
period. Following contact, the tradi- 
tional pattern expanded to include the 
movement of horses and European 
goods. The Arikara intensified their 
horticultural activities during the early 
contact period to produce surpluses for 
exchange. 

The early contact period before 1 750 
has been described as a prosperous and 
stable period for the Arikara as re- 
flected archeologically in the number 
and sizes of their villages and associ- 
ated midden deposits. Cache pit size 
and number increased during this 
period suggesting increased hor- 
ticultural productivity (Lehmer and 
Jones 1968). Some evidence also sug- 
gests that shifts in climatic conditions 
produced perceptible differences in the 
archeological patterns of Extended 
Coalescent and Post-Contact Coales- 
cent sites: 



Zagreb Paleopathology Symp 1988 



Femoral cortical thickness of North American Plains Indians • 109 



The Extended Coalescent settlement 
pattern of small villages occupied for 
only a short time may represent a re- 
sponse to marginal economic condi- 
tions, which in tum were the product 
of a less favorable climate. . . . 
Bryson has suggested (Baerreis and 
Bryson, 1965) that the Neo-Boreal 
conditions were modified somewhat 
during the first half of the 18th cen- 
tury. The larger and more permanent 
Post-Contact Coalescent settlements 
in South Dakota may represent a re- 
sponse to this improvement in cli- 
mate. (Lehmer 1971:128) 
Late 1 7th and early 1 8th century popu- 
lations in general were well off. As re- 
flected by increased cortical thickness 
and cortical area, the transition from 
the Late Prehistoric to the Early Pro- 
tohistoric was marked by a positive 
change in nutritional status. A culmina- 
tion of factors insured greater reserves 
and diversity of resources that buffered 
the villages against lean times. These 
factors included agricultural inten- 
sification to acquire surpluses for trade 
and increased availability of meat ob- 
tained through hunting and trade. 

Horses, first brought to the valley 
from the southwest, circa 1739, were a 
valued commodity in the middleman 
trade, both as an object of trade and as 
pack animals. Given the lag time be- 
tween their introduction, initial use as 
pack animals, and later use for riding, 
the impact of the horse on the Ankara 
economy would have been most signifi- 
cant after 1750 (D.J. Blakeslee, pers. 
comm.; Ewers 1955). Theoretically, 
horses made it easier to locate and kill 
wild game and to transport larger quan- 
tities of meat to the village than possi- 
ble during the prehistoric period when 
dogs were used for this purpose (Holder 
1970). The acquisition of the horse, 
with a corollary increase in high- 
quality protein in the diet, has been in- 
terpreted as a primary reason why Post- 
Contact Coalescent villagers show in- 
creased femoral cortical thickness rela- 
tive to their late prehistoric Extended 
Coalescent antecedents (Cashion 1987; 
Owsley 1985). Yet, as apparent in this 



more finely graded temporal analysis, 
the Late Protohistoric period (1740- 
1795) was not accompanied by dramat- 
ic increases in femoral cortical thick- 
ness. In fact, a subtle reverse occurs. 
Medullary cavity diameters increased 
markedly and mediolateral cortical 
thicknesses began to drop. In contrast, 
cortical areas did increase slightly be- 
cause of the larger values for T. Al- 
though this apparent inconsistency is 
not easily interpreted, it is clear that the 
major change (improvement) in Post- 
Contact period nutritional status pre- 
ceded the arrival of the horse. Any po- 
tential nutritional benefits derived from 
use of the horse were less significant. 
Later effects of Euro-American con- 
tact were negative and disruptive. Dis- 
organized Coalescent villages suffered 
higher levels of morbidity, population 
losses from disease and warfare, and 
sociocultural deterioration. "Between 
1738 and 1845, there was considerable 
instability of population marked by vil- 
lage abandonment and relocation" 
(Ramenofsky 1987:104). Catastrophic 
population losses followed the intro- 
duction and diffusion of acute infec- 
tious diseases, including cholera, mea- 
sles, smallpox and whooping cough 
(Lehmer 1971; Ramenofsky 1987; 
Trimble 1979,1985). Moreover, inter- 
tribal conflict escalated as militant 
nomadic groups moved into the middle 
Missouri region after being pushed out 
of the eastern woodlands. Arikara rela- 
tions were poorest with the Dakota 
Sioux, who arrived circa 1730-1740 
(Owsley et al. 1977; Smith 1980). The 
Sioux placed increasing pressure on the 
Arikara as conflict over bottom lands, 
which provided protection during the 
harsh winters, and competition for 
trade booty and the yield from the 
Arikara gardens intensified. The period 
of most intense warfare with the Sioux 
dates to the historic period after 1790 
(D.J. Blakeslee, pers. comm.). Tru- 
teau's journal for his journey of 1794- 
1796, for example, mentions an ex- 
pected attack on an Arikara village by 
500 Sioux warriors well armed with 
guns(Truteau 1913-1914). 



The nutritional effects of these 
changes are clearly registered in in- 
creased medullary cavity diameters and 
net reductions in femoral cortical bone 
during the early Historic period. 
Females seem to have been most af- 
fected by the stresses of this turbulent 
era. Although the direction and pattern 
of change in bone mass are evident, es- 
timated cortical areas were still higher 
than during the Late Prehistoric period. 

In summary, cortical bone thickness 
has proven to be a sensitive indicator of 
changes in Arikara nutritional status 
caused by environmental change. In 
contrast, maximum long bone length 
has not shown a significant response. 
The difference between these variables 
merits further consideration. More- 
over, future research must examine 
changes reported for the variable T. To- 
tal subperiosteal diameters increased 
through time, especially in males. Re- 
cent research concerning the geometric 
properties of lower limb bone di- 
aphyses has shown the responsiveness 
of cross-sectional shape to different 
mechanical loadings associated with 
behavior such as more frequent running 
(Ruff 1987). Perhaps the increase in T 
was a structural response to changes in 
activity level. In the future, we plan to 
consider possible variations in geo- 
metric form by examining both the me- 
diolateral and anteroposterior axes and 
direct measurement of cross-sectional 
area. 

Acknowledgments 

William Bass and Douglas Ubelaker 
kindly granted permission to examine 
these collections. Archeological recov- 
ery was made possible by grants from 
the National Science Foundation and 
the National Geographic Society. Don- 
ald Blakeslee and Daniel Rogers pro- 
vided archeological and cthnohistorical 
information. Steve Symes, Terry 
Zobeck, and Maria Cashion were re- 
sponsible for bone radiography and os- 
teometry. Suggestions concerning ana- 
lytical methodology were provided by 
J. Dequeker. Dana Bovee helped pre- 



Zagreb Paleopathology Symp. 1988 



no* Douglas W. Owsley 



pare this manuscript. The illustrations 
were provided by Ethan Ericksen. Data 
collection and analysis were supported 
by NSF BNS-8 102650 and BNS- 
8510588. 



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Summary of audience discussion: Poro- 
tic hyperostosis is not a useful indicator for 
stress in this population since the avail- 
ability of bison prevented protein deficien- 
cy. Dental hypoplasia was absent and trans- 
verse (Harris") line frequency was not 
elevated. The pattern of native population 
decimation secondary to infectious disease 
shortly after contact with the early colonists 
is absent in the Plains population reported 
here. The native population was large, and 
initially the number of foreigners was low. 
In fact, the availability of horses enhanced 
the bison harvest and trade ameliorated the 
effects of drought. Not until after 1750 did 
the effects of the flow of eastern colonists 
moving to and through the Plains become 
apparent in the natives with a reduction in 
child growth and increased frequency of 
premature delivery and the development of 
an increase in both medullary diameter and 
the subperiosteal diameter. It is clear that 
Norden's Index is only of relative value. 



Zagreb Paleopathology Symp. 1988 



Ethnohistorical accounts as a 

method of assessing health, disease, and 

population decline among Native Americans 



Marc A. Kelley 



Paleopathological inquiry, while typically relying on surviv- 
ing hard and soft tissues, can also benefit from a variety of 
other sources. These include artistic representations (paint- 
ings, engravings, ceramics), coprolites, early medical texts 
(e.g., Greek, Roman, Chinese) and, as in this study, eth- 
nohistoric accounts. These accounts, when used in conjunc- 
tion with skeletal samples, not only provide meaningful in- 
sight into disease patterns present at time of contact between 
two cultures, but also record natives' accounts of afflictions 
and treatments existing prior to contact. I shall focus on the 
Contact and early Historic periods of New England to dem- 
onstrate the utility of this approach. 

European contact with New England natives 

As any American historian knows, the landing of the 
Plymouth Pilgrims in 1620 was preceded by more than 120 
years of exploration, trade, Indian abduction into slavery, 
and foiled attempts at settlement on New England soil. Table 
I lists the official voyages from Europe, as well as some of 
the unofficial expeditions. The actual number of unofficial 
journeys will never be known, but no doubt well exceeds the 
documented trips. 

From an epidemiological point of view, certain events dur- 
ing the exploratory period deserve closer attention. Hundreds 
of fishing vessels were visiting areas south of Newfoundland 
each year during the second half of the 16th century (Fite and 
Reese 1965; Brasser 1978). In 1602 Gosnold encountered 
natives wearing pieces of European clothing and understand- 
ing a fair number of European words (Purchas 1625). Five 
years later Popham and Gilbert attempted to establish a col- 
ony on the Maine coast (Winship 1968). This was abandoned 
a year later. In 1616 two different parties, headed by Vines 
and Hawkins, respectively, wintered at coastal ItKations in 
Maine (Gorges 1658; Howe 1942). One member of the 
Gorges party. Richard Vines, observed the natives to be suf- 
fering a plaguelike disease to which the English were 
seemingly immune (Gorges 1658). A few years later large 

Zagreb Paleopathology Symp. 1988 



tracts of New England were nearly void of inhabitants, thus 
paving the way for the Plymouth Pilgrims. 

Chronology of epidemics 

A close inspection of ethnohistorical documents suggests 
that the devastating plague arising in 1616 in New England 
was preceded by several pestilences in the second half of the 
16th century. After an earthquake rocked New England in 
1638 the founder of Rhode Island, Roger Williams, ques- 
tioned the Narragansett elders regarding earlier earthquakes 
and found that they not only remembered previous earth- 
quakes but associated each one with an epidemic: 

The younger natives are ignorant of the like; but the elders 
inform me that this is the fifth |carthquake] with these 4 
score years in the land: the first about three score and ten 
years since: the second some 3 score and four years since, 
the third some 54 years since and the fourth some 46 since: 
and they always observe either Plague or Pox or some other 
epidemical disease followed; 3, 4 or 5 years after the earth- 
quake. (LaFantasie 1988:159-160) 

While the earthquake/epidemic dualism may be a meta- 
phor of Algonquian speech, the existence of epidemics is 
not. According to the elders the date for these epidemics was 
1572 ± I year, 1578 ± 1 year, and 1597 ± 1 year. However, 
if the Narragansetts had been affected by four epidemics their 
numbers were surprisingly robust by the early 17th century. 

The so-called plague which began in 1616 continued at 
least until 1619 (Cook 1973b), perhaps until l622(Winslow 
1841; Morton 1632), and swept away untold thousands of 
Indians. Graphic accounts have been passed down to us by 
several explorers and settlers. Thomas Morton (1632:18- 
19), for example, described scenes near Boston as follows: 

They died on hcapes, as they lay in their houses and the liv- 
ing; that were able to shift for themselves would runnc 
away, and let they dy. and let there carkases ly above the 

III 



112 • Marc A. Kelley 



Table l. European voyages to New England prior to 
A.D. 1620 



Date 


Voyage 


1497 


Cabot 


1500-01 


Cortereal 


1524 


Gomez 


1524 


Verra/Tano 


1527 


Rut Voyage (English, unofficial) 


1530 


Crignon 


1536 


Unofficial English voyage 


1550 


Approx. 60 ships/yr-Newfoundland 


1555 


Thevet (Maine, 5 days) 


1568 


Ingram 


1578 


Approx. 400 fishing ships/yr 


1579 


Fernadex 


1580 


Walker 


1583 


Gilbert 


1600 


200 English fishing ships/yr alone 


1602 


Gosnold 


1603 


Pring 


1604 


Champlain 


1605 


Champlain 


1605 


Waymouth 


1606 


Champlain 


1606 


Hanham and Pring 


1607 


George Popham and Gilbert 


1609 


Hudson 


1610 


Argall 


1611 


Harlow 


1611 


Biard (Jesuit) 


1614 


Block 


1614 


Smith 


1614 


Francis Popham 


1614 


Hunt 


1614 


Hobson 


1615 


Dermer 


1616 


Gorges expedition wintered in Maine 


1616 


Hawkins party wintered in Maine 


1619 


Dermer 


1620 


Plymouth Pilgrims land 



Sources: Howe 1942, McManis 1972, Purchas 1625, 
Winship 1968. 



ground without burial!. For in a place where many inhab- 
ited, there hast been but one left a live, to tell what became 
of the rest, the llvingc being (as it seemes) not able the 
bury the dead . . . and the bones and skulls upon the sever- 
all places of their habitations, made such a spectacle after 
my comming into those partes, that as I travailed in that 
forrest, nere the Mas.sachussets, it seemed to mee a new 
found Golgatha. 

In terms of geographic range, the coastal natives from 
Caf)e Cod to the Penobscot River (Maine) were the principal 
targets of this epidemic. That the Narragansetts were spared 
its effects is a point agreed on by all early authors (Winthrop 
1908; Gookin 1792; Williams 164.3). Possible explanations 
for the spared Narragansetts include the Narragansett Bay, 
which served as a natural barrier (Cook 1976), and weak 
social and trade relations between northern and southern 
New England tribes. 

The exact agent or agents responsible for this pestilence 
remains obscure, but the following observations can be 
made: disease was not stayed by frost; English apparently 
were not susceptible; survivors exhibited sores upon their 
bodies; some Indians' bodies were exceedingly yellow; dis- 
ease affected Indians only 20-30 miles inland; up to 90% 
mortality observed in some places; Indians well acquainted 
with smallpox claim this to be a different disease. 

The extremely high mortality rate resulting from the 1616 
pestilence is inconsistent with most epidemiological models, 
and 1 propose that this pestilence actually represented an 
unfortunate convergence of two or more diseases over a 3- 
6-year period. Probable pathogens include a form of the 
plague, yellow fever, and infectious hepatitis (see Spiess and 
Spiess 1987 for the argument supporting infectious hepatitis) 
exacerbated by inadequate health care delivery systems, so- 
cial disruption, and famine. Indeed, evidence in support of a 
series of sweeping epidemics may be gleaned from John 
Smith's "Advertisements for the Unexperienced ..." in 
which he states: "Three plagues in three years successively 
neere 200 miles along the Seacoast that in some places there 
scarce remained 5 of a hundred" ( 163 1 :9). 

The next major epidemic in New England was smallpox 
from 1633 to 1634. Bradford's graphic account deserves 
some mention: 

They fall into a lamentable condition as they lie on their 
hard mats, the pox breaking and mattering and running one 
into another, their skin cleaving by reason thereof to the 
mats . . . they fell down so generally of this disease as they 
were in the end not able to help one another, no not to 
make a fire nor to fetch a little water to drink, nor any to 
bury the dead. (1970:270-271) 

Some 950 Massachu.sett Indians (Bradford 1970:270- 
27 1 ) and 700 Narragansett Indians (Winthrop 1908: 1 1 8) died 
as a result of this epidemic. Indian groups further inland were 
extensively affected as well. 

Zagreb Paleopathology Symp. 1988 



Historical accounts in assessing paleopathology of Native Americans • 113 



Table 2. 


Epidemics in 


New England 


Table 3. Examples of plant remedies used 
by early native Americans 


Date 


Disease 


Tribe/Region 


Remedy 


Disease/Ailment 




Unknown 


Narragansetts 


1568 






1574 


Unknown 


Narragansetts 


Alder 


Bruises, sprains, head 


1584 


Typhus? 


Narragansetts 




and back aches 


1592-93 


Smallpox 


Narragansetts 


Balsam poplar 


Burns, cuts, bruises 


1616-19 


"Plague" 


New England, except 


Bear berry 


Scurvy 






Narragansetts 


Blackberry 


Dysentery 


1633-34 


Measles or 


New England, ind. 


Burdock 


Rheumatism 




smallpox 


Narragansetts 


Dandelion 


Rheumatism 


1647 


Influenza 


New England Tribes 


Garlic 


Arteriosclerosis, high 


1649-50 


Smallpox 


Northeastern Tribes 




blood pressure 


1659 


Diphtheria 


New England and 


Ginseng 


Old age aches/pains 






Canada 


Goldenrod 


Kidney disease 


1664 


Smallpox 


Massachusett Indian 


Hardback 


Dysentery 


1669-70 


Smallpox 


French & British people 


Irish moss 


Bronchitis 






in Northeast 


Jack-in-the-pulpit 


Sore throat, coughs, 


1677-79 


Smallpox 


Northeastern Tribes 




tuberculosis 


1713-15 


Measles 


New England Tribes 


Lobelia 


Dysentery, epilepsy 


1729-33 


Smallpox 


New England Tribes 


Pipsissewa 


Stomach disorders 


1735-36 


Diphtheria 


New England Tribes 


Poke 


Cancer 


1746 


Smallpox 


New York & New England 


Sassafrass 


Respiratory ailments 






Tribes 


Sea tears 


Scurvy 


1755-60 


Smallpox 


From Canada to 


Snake root 


Snakebites, pneumonia 






Northeast 


Thistle 
Tohacco 


Tuberculosis 
Earache 


SOURCES: 


: Bradford 1970, Cushman 1622, DeForest 


White Hellibore 


Toothache 


1852, Dermer 1619, Dobyns 1983, Hubbard 1815, 


Wild carrot 


Diabetes 


James 1%3, Jameson 1910, White 1630, Young 1846. 


Wild grape 


Headache, fever 








Wild plum 


Asthma 



The 1 633-34 epidemic signaled the last of the large-scale, 
acute disease episodes for New England Indians (see Table 
2). While outbreaks of smallpox and other infections oc- 
curred intemiittently in the years to follow, mortality levels 
were much lower by necessity of the fact that substantially 
fewer Indians remained. The question now arises, why did 
introduced diseases decimate 25% , 50%, or sometimes even 
95% of the Indians? Can this be attributed solely to genetic 
susceptibility? 

I should now like to examine more closely the health care 
systems of 17th century Native Americans and Europeans 
respectively. 

New World and Old World technologies 

Native New England pharmacopoeia was quite adequate for 
dealing with wounds, burns, snake bites, pulmonary ail- 
ments, toothaches and body aches (Josselyn 1674), but vir- 
tually no remedies existed for Old World pathogens such as 

lagrrb Paleopathology Symp. 1988 



SOURCES: Josselyn 1674, Krochmal and 
Krochmal 1973, Tantaquidgeon 1925-26, 
Thomson 1978, Vogel 1970. 



plague, smallpox, measles, yellow fever, or influenza. Table 
3 lists a small sampling of remedies for common ailments 
reportedly used in prc-Contact times. This is not to say that 
the colonists possessed a vast knowledge or set of remedies 
for such diseases. Even in the 20th century, we possess few 
drugs for treating viral infections. The 17th century colonial 
medical knowledge was so scant that John Winthrop was 
impelled to write to London for instruction on treating com- 
mon ills. The brief eight-page reply, which served as the 
early colonists" principal source of medical knowledge, con- 
tained potions and elixirs certainly of no greater sophistica- 
tion than practices by the Indians. 

What the Europeans did possess was a familiarity with 
various Old World viral and bacterial maladies and the 



114 • Marc A. Kelley 



efficacy of providing simple attendance to the ill — namely, 
insuring bedrest, warmth, plenty of fluids and emotional 
comfort. Edward Winslow's account (1841 ) of his treatment 
of the nearly dead Sachem Massasoit in 1623 is enlightening. 
The Sachem, in an advanced state of illness (suffering possi- 
bly from an intestinal virus) had lost his sight, his tongue had 
swollen, and he suffered from dehydration. Winslow admin- 
istered some physick (which usually consisted of raisins, 
currants or other fruit), he then scraped the Sachem's tongue 
and was able to mix water with the physick. which Massasoit 
readily consumed. Within a half hour or so, Massasoit was 
improving, as was his vision. 

So here we see that a man on the brink of death was aided 
by the simple administration of water and fruit, not by any 
sophisticated medical technology. As Massasoit continued to 
improve, Winslow graduated him to chicken broth, which 
made him stronger still. The colonists realized the value of 
fluids and the danger of fatty foods during recovery from 
such illnesses, but unfortunately the Indians did not. During 
his recovery, Massasoit nearly died a second time by gorging 
himself on fatty duck meat. As we know, Massasoit did 
survive and lived a long life, but thousands of other natives 
lost their lives abruptly because of unattended simple needs 
of the sick. 

With this in mind, let us once again examine passages 
from Governor Bradford's journal concerning Indian suffer- 
ing and lack of basic health care: 

And then being very sore, what with cold and other dis- 
tempers, they die like rotten sheep. The condition of this 
people was so lamentable and they fell down so generally 
of this disease as they were in the end not able to help one 
another, no not to make a fire nor to fetch a little water to 
drink, nor any to bury the dead. But would strive as along 
as they could, and when they could procure no other means 
to make fire, they would bum the wooden trays and dishes 
they ate their meat in. and their very bows and arrows. And 
some would crawl out on all fours to get a little water, and 
sometimes die by the way and not be able to get in again. 
(1970:271, italics mine) 

This passage indicates that (1) a synergism existed be- 
tween smallpox and other distempers, which inevitably led to 
higher mortality rates than otherwise expected, (2) most 
members of a tribe were sick simultaneously, and (3) basic 
health needs went unattended. The English eventually took 
pity on the suffering Indians and tried to help them, but by 
then, one suspects, it was too late. One additional factor 
would have contributed to the natives' downfall: the psycho- 
logical despair and apathy associated with epidemic sick- 
ness. For example. In the 2()th century, outbreaks of viruses 
among remote South American tribes lead to a fatalistic out- 
look among not only those affected, but the unaffected as 
well. Had not the medical researchers intervened, mortality 
levels would certainly have been high. 



The differences between European and Indian strategies 
for health care are thus obvious, but can we attribute such 
staggering mortality rates among the Indians simply to health 
care differences? For example, it has been argued that the 
Indians possessed greater genetic susceptibility to Old World 
pathogens. While this may in small part be true, I believe it 
has been greatly exaggerated by medical historians over the 
last several decades. It is important to remember that, though 
not so dramatically, smallpox, influenza, yellow fever, and 
tuberculosis claimed a steady toll of colonists each year. 
Such diseases were feared by both races. The possibility 
exists that Indians lacked certain acquired immunities to Old 
World pathogens. Viral infections such as measles and small- 
pox confer lifelong immunity if the victim survives. Euro- 
pean immigrants were much more likely to have been ex- 
posed to such viruses in the high-density towns and cities of 
Europe and thus be immune to subsequent outbreaks occur- 
ring in the New World. 1 remain unconvinced that Europeans 
possessed an inherent genetic resistance to these viruses. 
Smallpox, for example, seems to have been imported from 
Asia into Europe only a few centuries prior to exploration of 
the New World. It would seem unlikely that any appreciable 
natural selection could have occurred among Europeans dur- 
ing that interval. 

In effect, the bulk of evidence would suggest that while a 
certain amount of loss of life from imported disease was 
unavoidable, the devastating epidemics suffered by Indians 
were not necessarily inevitable. 

Case study: Life for mid- 17th century 
Narragansetts after the viral epidemics 

The recent discovery and excavation of a Narragansett ceme- 
tery dating between 1650 and the 1670s (see Robinson et al. 
1985 for additional background) provide us with an ideal 
opportunity to examine the biosocial context of the epi- 
demiological transition to an endemic disease setting among 
these natives. This cemetery was located only three miles 
from where Richard Smith and Roger Williams had set up a 
trading post in 1637 or 1638. There is little doubt that these 
Indians experienced frequent and sustained interaction with 
the English settlers. 

Aspects of Indian acculturation included employment by 
the colonists to build stone walls (Gookin 1792), the tending 
of livestock and use of English mills for maize from the 
1640s onward (Cronan 1983; Lechford 1867; Williams 
1874), and the widespread detrimental consumption of alco- 
hol . This last factor was of suftlcicnt magnitude to prompt the 
Rhode Island colonists to pass legislation prohibiting the sale 
of liquor to the natives at least five times during the 1650s 
(Bartlett 1856). The rich diversity of European goods buried 
among the 56 members coupled with skeletal evidence of 
certain chronic disease states provide further evidence of this 
coexistence. 



Zagreb Paleopalholofiy Symp. I9S8 



Historical accounts in assessing paleopathology of Native Americans • 115 



The skeletal remains indicate an extraordinarily high fre- 
quency of skeletal tuberculosis with 30% of the cemetery 
exhibiting lesions of the spine, ribs and/or hip (Kelley and 
Robinson in prep; Robinson etal. 1985; Kelley 1986). Since 
not all individuals with tuberculosis exhibit skeletal lesions, 
the number of individuals suffering from this infection must 
have been considerably higher. 

The rise in tuberculosis rates among New England Indians 
was noticed by some colonists even during the 17th century. 
In the 1690s Daniel Gookin made the following, rather re- 
markable statement: 

Sundry of those Indian youths dies, that were bred up to 
school among the Knglish. The truth is, this disease is fre- 
quent among the Indians; and sundry die of it, that live not 
with the English. A hcctick fever, issuing in a consump- 
tion, is a common and mortal disease among them. / know 
some . . . have attributed it unto the great change upon 
their bodies, in respect of their diet, lodging, apparel, stud- 
ies; so much different from what they wer inured to among 
their own countrymen. (1792:173, italics mine) 

The association between altered lifestyle and elevated tu- 
berculosis rates is widely acknowledged today. Figure 1 de- 
picts the Rl-1000 burial ground plan. An interesting pattern 
emerges when individuals with tuberculous lesions are col- 
ored in. Whether this represents disease spread within sever- 
al family households, or a flare-up of tuberculosis in the 
community, or enhance chance distribution is uncertain. 
Williams's description of the Narragansett social practice of 
visiting the sick is perhaps insightful. He wrote: 

The visit of friends, and neighbours, a poore empty visit 
and presence, and yet indeed this is very solemne, unlesse 
it be in infectius diseases, and then all forsake them and 
flic, that I have often scene a poore house left alone in the 
wild woods, all being fled, the living not able to bury the 
dead: so terrible is the apprehensions of an infectious dis- 
ease, that not only persons, but the houses and whole 
towne takes flight. (Williams 1643:210) 

Such a practice may have been a key element in postepidemic 
Narragansett decline. Crowding around or simply cohabitat- 
ing with a sick person who was perceived as not suffering an 
infectious disease (which would almost certainly include 
chronic tuberculosis) could result in the pattern observed in 
Figure 1. 

In humans, tuberculosis occurs as an acute or chronic 
infection caused by either Mycobacterium tuberculosis (hu- 
man form) or Mycobacterium bovis (bovine form). The hu- 
man form is primarily transmitted from person to person by 
inhalation of the bacilli into the lung. This pulmonary infec- 
tion, which is often contracted during infancy and childhood, 
may spread rapidly to other portions of the body or become 
encapsulated and remain dormant for years or decades. The 
extreme prevalence of tuberculosis was (and continues to be 



0' 



<9 



6>, 



Rl 1000 



e 



PLAN OF BURIALS ^ 6^ 






o 






e 






& 










& 



< /' "x* / «, Oltplacid burlolt 
"^ ' '> ^. / 1,5.6,7,53-57 

Figure 1 . Rl-1000 burial ground plan. Shaded areas indicate 
individuals displaying skeletal manifestation of tuberculosis. 



in certain areas of the world today) due to such factors as 
malnutrition, overcrowding, war. social upheaval, poverty, 
alcoholism, and smoking (Lester 1981:972; Burnet and 
White 1975:217). At least some of these conditions were 
present in mid- 17th century southern New England Indian 
communities. 

Certainly other infectious diseases were taking a toll 
among the Narragansetts. Pneumonia and dysentery (gas- 
troenteritis), while not leaving any telltale lesions on the 
bones, are noted in early accounts (Williams 1643) and in- 
deed are still a serious problem in American Indians today. 
Evidence for a treponemal infection at Rl-1000 was noted in 
one young adult female. The nasal cavity is extensively de- 
stroyed and the young woman's hands were placed imme- 
diately in front of her face — a pattern not seen in the other 
burials. Williams (1643) reported that the Narragansett "hot- 
house" was used in treating the French disease (i.e., syph- 
ilis). Finally, one all-pervasive, chronic disease present at 
Rl-1000 was severe dental disease (see Kelley et al. 1987 for 
detailed discussion). 

Each of these chronic conditions was capable of directly or 
indirectly claiming human life and no doubt contributed to 
the steady attrition of New England Indians in the mid- 17th 



Zagreb Pateopathotogy Symp. 1988 



116 • Marc A. Kelley 



century. However, this attrition was not nearly so dramatic or 
devastating as were the eadier viral epidemics. Conceivably 
such native American groups eventually would have reached 
an equilibrium and the population would have begun to grow 
again. This scenario, however, apparently did not fit into the 
colonists' larger plan. Those who avoided death from mi- 
crobes would next contend with guns and swords. It is widely 
acknowledged that warfare tactics differed for Europeans and 
Indians. The more ritualistic and symbolic style of warfare 
often practiced by Native Americans prompted Roger 
Williams to write: 

Their warres are farre Icssc bloudy. and devouring then the 
cmell warres of Europe; and seldomc twenty slaine in a 
pitcht field: partly because when they fight in a wood every 
tree is a bucklar. When they fight in a plaine. they fight 
with leaping and dancing, that seldome an arrow hits, and 
when a man is wounded, unless he that shot follows upon 
the wounded, they soone retire and save the wounded: and 
yet having no swords, nor guns, and all that are slaine are 
commonly slain with great valour and courage: for the con- 
querour ventures into the thickest, and brings away the 
head of his enemy. (1643:204) 

The Narragansetts objected to the English warfare style, 
according to John Underbill (1638), because it "slays too 
many men." Furthermore, the natives had traditionally 
spared the lives of women and children, a practice not at all 
observed by the Dutch and English. While Indians slain dur- 
ing battle and massacres obviously contributed to population 
decline, the more profound blow occurred in the aftermath of 
hostilities — more specifically, the colonial practice of de- 
stroying com fields and supplies. The result, of course, was 
famine and more disease — thus providing the rationale for 
including both disease and warfare in this report. An exam- 
ination of Cook's tabulation of Indian losses during King 
Philip's War (1675-1676) illustrates the magnitude of sec- 
ondary losses (Cook 1973a:21): 

1 ,250 killed in battle 
625 died of wounds 
3 ,000 died of exposure and disease 
1 ,000 sold as slaves 
2,000 permanent refugees 
7,875 total lost 
3,875 remaining 
1 1 ,600 Total 

For the Narragansetts. who had been relatively fortunate 
with regard to introduced disease. King Philip's War effec- 
tively reduced them to a remnant population. Table 4 high- 
lights the fate of 17th century Narragansetts by comparing 
them to McElroy and Townsend's (1985) medical model for 
19th century Canadian Inuit natives. This table lists the 
stages of contact on one axis and the epidemiologic, demo- 
graphic, nutritional, and health care subsystems on the other 
axis. Stage 1 is identical for each group. Stage II remains 



quite similar, but Stage III departs radically. Instead of popu- 
lation rebound, we see heavy warfare losses and subsequent 
famine, exposure, and disease. In addition, there was essen- 
tially no governmental assistance in the 1 7th century. In 
effect, 17th century natives had to face a deadly double- 
edged sword of epidemics and warfare. 

To sum, the use of ethnohistorical records can prove en- 
lightening in our effort to better understand the health pat- 
terns of early human populations. It is imperative to remem- 
ber, however, that clinical descriptions can be vague (as well 
evidenced by the long-enduring controversy of syphilis ori- 
gins based on written records). Nonetheless, many diseases 
are much less controversial (e.g. , dysentery, measles, small- 
pox) and the ethnohistoric record can provide insight in such 
cases whereas the skeletal remains cannot. Where circums- 
tances permit, this author recommends careful scrutiny and 
utilization of these alternate resources. 

Literature cited 

Bartlett, J.R. 1856. Records of the Colony of Rhode Island and 
Providence Plantations in New England, vol. I (1636-1663). 
Providence. R.I.: Greene and Brother. 

Bradford, W. 1970. Of Plymouth Plantation 1620-1647. New 
York: Alfred A. Knopf. 

Brasser, T.J. 1978. Early Indian-European Contacts. In B.C. Trig- 
ger, ed.. Handbook of North American Indians, vol. 15, North- 
east. Washington, D.C.: Smithsonian Institution Press. 

Burnet, M., and D.O. White. 1975. Natural History of Infectious 
Disease. 4th edition. New York: Cambridge University Press. 

Cook, S.F. 1973a. Interracial Warfare and Population Decline 
among the New England Indians. Ethnohistory. 20:1-24. 

1973b. The Significance of Disease in the Extinction of the 

New England Indians. Human Biology. 45:485-508. 

1 976. The Indian Population of New England in the Seven- 



teenth Century. Publications in Anthropology, vol. 12. San Fran- 
cisco: University of California Press. 

Cronan. W. 1983. Changes in the Land: Indians. Colonists, and the 
Ecology of New England. New York: Hill and Wang. 

Cushman, R. 1622. Cushman's Discourse. In A. Young, cd.. 
Chronicles of the Pilgrim Fathers of the Colony of New Plymouth 
from 1602-1625. Boston: C.C. Little and J. Brown. 

DeForcst, J.W. 1852. History of the Indians of Connecticut from the 
Earliest Known Period to IS50. Connecticut Historical Society. 
Hartford, Conn.: W.J. Hammersley. 

Dermer, T. 1619. Letter to His Worshipfull Friend Samuel Purchas, 
Preacher of the Word, at the Hurcha a Little within Ludgate. 
London. In Purchas. vol. 19 (1905-1907). Glasgow: J. Mac- 
Lehose and Sons. 

Dobyns, H.F. 1983. Their Number Became Thinned: Native Ameri- 
can Population Dynamics in Eastern North America. Knoxville: 
University of Tennessee Press. 

File, E.D., and R. Reese. 1965. An Economic History of the United 
Slates. Boston: Houghton Mifflin. 

Gookin, D. 1792 1 16931. Historical Collection of Indians of New 
England. Massachu.selts Historical Society Collections, scries 1, 
vol. I. 

Zagreb Paleopathology Symp. 1988 



Historical accounts in assessing paleopathology of Native Americans • 117 



Table 4. Comparative medical models 




Medical model for 19th 


1 century native American Indian 




Stage I 


Stage II 


Stage III 




(pre-contact) 


(contact) 


(post-contact) 


Epidemiology 


Few pathogens in 


Epidemics of 


Hypcrendemic 




ecosystem; low 


infectious 


infectious and 




immunities to 


diseases 


nutritional diseases 




mfections 






Demography 


Births = deaths, 


Births < deaths. 


Births > deaths, 




population stable 


population decline 


population growth 


Nutrition 


High protein, 


Carbohydrate 


High carbohydrate. 




low carbohydrate; 


supplements; 


low protein; food 




fluctuating supply 


famine interacting 


supply steady but 






with epidemics 


nutritionally poor 


Health care 


Shamans and 


Shamans discredited 


Government and 




midwivEs fulfill 


in epidemics; 


missions provide 




limited medical and 


missions provide 


modern medical care 




psychotherapeutic 


relief 






needs 








Modified medical model for 17th century Narragansetts 




Stage I 


Stage II 


Stage III 


Epidemiology 


Few pathogens b 


Epidemic of 1633 


Hyperendemic 




ecosystem; low 


killed 700 


infectious and 




immunities to 




nutritional diseases 




infections 






Demography 


Births = deaths 


Birth < death. 


Steady attrition of 




population stable 


population decline 


population followed by 






occurs gradually 


rapid decline during 
King Philip's War, 
1675-76 


Nutrition 


High protein, low 


Carbohydrate 


Widespread famine 




carbohydrate; 


consumption 


in aftermath of war 




fluctuating supply 


increases with 
introduction of 
sugar and flour 




Health care 


Tribal medicine men 


Relatively light loss 


Little or no 




fulfill limited medical 


of life compared to 


government assistance 




and psychotherapeutic 


other New England 


to surviving 17th 




needs 


tribes, medicine men 
not discredited 


century Narragansetts 



NOTE: 19th century model adapted from McElroy and Townsend 1985. 

Zannb Paleopathology Symp. I9HH 



118 'Marc A. Kelley 



Gorges, F. 1658. A Briefe Narration of the Original Undertakings 
of the Advancement of Plantations in Parts of America. London; 
E. Brudencll for N. Brook (Prince Soc. 1X90). 

Howe. H.F. 1942. Sources of New England Indian History prior to 
1620. Massachusetts Archeological Society Bulletin, 3:19-24. 

Hubbard, W. 1815. /I General History of New England from the 
Discovery to 1680. Massachusetts Historical Society. 
Cambridge, Mass.: Hillard and Metcalf. 

James, S.V., ed. 1963. Three Visitors to Early Plymouth. Letter 
from E. Altham to Sir Ed. Altham (Sept. 1623). Massachusetts: 
Plymouth Plantation. 

Jameson, F. , ed. 1910. John.son's Wonder Working Providence 
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Summary of audience discussion: Tuberculous involvement in 
one-third of an archeological population is an unprecedented rate. 
The author of this study defended his diagnosis on the basis of 
including only lesions characteristic of tuberculosis seen in the 
spine, hip and ribs. Costal periostitis in an appropriate pattern re- 
flects the presence of empyema of tuberculous origin since it could 
not be identified on x-ray in 400 modern patients with pyogenic 
pneumonia. Such a study, however, needs to be carried out on 
modem patients with pyogenic empyema. Recognition of charac- 
teristic, empyema-induced tuberculous costal periostitis in an ar- 
cheological population will usually double the tuberculous frequen- 
cy predicted by the more traditional measures. Known close 
interaction between these natives and the colonists makes highcr- 
than-usual frequencies of tuberculosis plausible. Since historical 
records in earlier periods may be influenced by imprecision of 
diagnostic tenninology and even by political influences (deriving 
from administrative, self-serving reports as may have occurred dur- 
ing the South African colonial era), such evidence should not be 
used in isolation but may, as in this case, be considered supportive. 



Zagreb Ptileopatholiiay Symp. t988 



Interpretation of infectious skeletal lesions 
from a historic Afro-American cemetery 



Jerome C. Rose and Philip Hartnady 



Afro-American history is a complex 
subject which has engendered consider- 
able interest and numerous debates in- 
volving not only historians, but an- 
thropologists and demographers as 
well. During Reconstruction (1865- 
1877) the lives of Afro- Americans 
went through numerous changes where 
the former plantation slaves undertook 
the transition from a life dictated by 
others to one of self responsibility. This 
transition was aided by temporary 
provision of housing, food, and medi- 
cal care by the occupying Union mili- 
tary forces and other agencies both gov- 
ernment and private (Stampp 1965). In 
contrast to the well-documented slav- 
ery era, health-related data for both the 
Reconstruction and post-Reconstruc- 
tion (1878-1930) periods are scarce 
and, at times, of questionable quality. 
No geographically specific understand- 
ing of Afro-American demographic 
processes between 1 860 and 1 930 can 
ever be achieved because of the ques- 
tionable quality of the 1870, 1890, and 
1920 censuses (Farley 1970:3). This 
scarcity of both demographic and dis- 
ease data can be attributed primarily to 
the lack of record keeping and inade- 
quate census procedures resulting from 
the turmoil of "carpetbag rule" in the 
former Confederacy and a continuation 
of this situation for Afro-Americans 
with the establishment of legalized seg- 
regation during the post-Reconstruc- 
tion period. Until recently, the skeletal 
remains of people from this time period 
have been largely unavailable. Yet, 
skeletal analysis can provide informa- 

Zagreh Paleopaihology Symp. IVHH 



tion critical to understanding the condi- 
tions of life and health during this his- 
toric period. 

The analysis of skeletal remains col- 
lected during the relocation of Cedar 
Grove (3LA97), a rural Afro- American 
cemetery in southwest Arkansas, is ide- 
ally suited for addressing issues of 
postemancipation health. Demograph- 
ic and paleopathological data are used 
to test the imperfect historic reconstruc- 
tions of postemancipation life and pro- 
vide a more detailed picture, at least for 
this sample, of diet, health, and the 
general quality of life. The analysis of 
the Cedar Grove skeletal sample also 
provides an opportunity to test the va- 
lidity of paleodemographic and paleo- 
pathological interpretations by compar- 
ing them with those derived from 
census data and historic documents. It 
is not uncommon for the utility of pa- 
leodemography to be called into ques- 
tion. For example, Bocquet-Appel and 
Masset (1982) contend that paleode- 
mography cannot provide a true or real- 
istic reconstruction of a population 
using skeletal data. Although this crit- 
icism has been clearly answered by a 
number of authors (Buikstra and 
Konigsberg 1985; Van Gcrven and Ar- 
melagos 1983), the Cedar Grove data 
are used to test the concordance of pa- 
leodemographic interpretations with 
those derived from census data. Sim- 
ilarly, doubts have often been raised 
concerning paleopathology, in particu- 
lar the inaccuracies of lesion diagnosis 
(see Ubelaker 1982:344-345) and the 
utility of using skeletal lesions to recon- 



struct disease patterns (see Buikstra and 
Cook 1980:439-440). Again, concor- 
dance between the paleopathological 
interpretations and the historic litera- 
ture is tested with the Cedar Grove ma- 
terial. 

Materials and methods 

During the construction of a revetment 
along the Red River, the U.S. Army 
Corps of Engineers encountered what 
was thought to be a small historic ceme- 
tery and a prehistoric American Indian 
farmstead. After determination of eligi- 
bility for nomination to the National 
Register of Historic Places, the marked 
historic graves were relocated and the 
prehistoric site excavated by the Ar- 
kansas Archeological Survey. During 
the excavation, an additional 104 un- 
marked grave outlines were located. 
Historic investigation established that 
this cemetery had been used by the 
Afro-American community associated 
with the Cedar Grove Baptist Church, 
which lost use of the cemetery when it 
was covered by almost two meters of 
silt during the 1927 flood. After exten- 
sive negotiations and legal determina- 
tions, those 79 graves scheduled for de- 
struction by revetment construction 
were excavated, analyzed, and relo- 
cated to a new cemetery. The skeletal 
remains and all associated grave con- 
tents were excavated using standard ar- 
cheological techniques and analyzed in 
a field laboratory prior to reburial in a 
new cemetery plot. All archeological 
and osteological analyses were con- 

119 



120 • Jerome C. Rose and Philip Hartnady 



ducted in the field within portable 
buildings brought to the excavation site 
and used laboratory and photographic 
equipment brought from the University 
of Arlcansas campus. All skeletal mate- 
rials were washed, inventoried, and 
photographed. Age for subadults was 
determined using dental development 
(Schour and Massler 1941) and epi- 
physeal union (Krogman and Iscan 
1986:50-97). Age determination for 
adults used pelvic criteria. Each pubis 
was scored using the Todd system with 
the Brooks modification (as cited in 
Krogman and Iscan 1986:148-154), 
and the pubic cast system for males 
(McKem and Stewart 1957) and fe- 
males (Gilbert and McKem 1973). The 
auricular surface age system employing 
both textual and photographic descrip- 
tions of each stage was also applied 
(Lovejoy et al. 1985). Macroscopically 
observed skeletal lesions were recorded 
using the system adapted by Powell 
(1985:433-434). This system records 
each pathological lesion by a numerical 
code, textual description, and color- 
coded drawings on a skeleton outline 
provided on the recording forms. The 
four-digit numerical code provides the 
following information: type of lesion 
(i.e., resorptive, proliferative, trauma, 
and neoplasm), location on bone, ex- 
tent of lesion, and status of lesion (i.e., 
active or remodeled). The textual de- 
scriptions and drawings provided clari- 
fication of the code for each lesion and 
a photograph was taken of each. The 
numerical code was entered, along with 
age and sex, into a computerized data 
base for this analysis. 

Results 

Both historical and archeological evi- 
dence established that all excavated in- 
dividuals were interred between 1890 
and 1927. The 79 excavated graves pro- 
duced a total number of 80 individuals, 
as one grave contained two individuals 
(seven-month in utero twins). The age 
and sex data (see Table 1) were ana- 
lyzed using an abridged life table fol- 
lowing the procedures of Swedlund and 
Armelagos (1976:63-64) and com- 



TabLE 1. Demography of the Cedar Grove 
historic cemetery 



Age 


Unknown 


Males 


Females 


Total 


Birth 


16 


— 


— 


16 


0.3 - 0.9 


6 


- 


- 


6 


1 - 1.9 


11 


- 


- 


11 


2 - 4.9 


1 


- 


- 


1 


5 - 9.9 


5 


- 


- 


5 


10 - 14.9 


5 


- 


- 


5 


15 - 19.9 


- 


1 


- 


1 


20 - 29.9 


- 


2 


4 


6 


30 - 39.9 


- 


3 


11 


14 


40 - 49.9 


- 


7 


3 


10 


50 + 


- 


2 


3 


5 


TOTALS 


44 


15 


21 


80 



Table 2. Percent active osteolytic/proliferative lesions by age in years 

Birth 0.1-0.9 1-5 6-10 11-29 30-39 40-50 50 + 



Basiocranium 


38 


50 


17 

















CaKarium 


44 


17 


17 

















Endocranium 


38 


17 


33 

















Frontal 


19 


17 


17 

















Orbit 


19 


33 


8 

















Maxilla 


6 























Mandible 


25 





8 

















Cervical 


6 























Thoracic 


6 





8 








7 








Lumbar 


6 





8 

















Ribs 


56 


33 


33 





11 


7 


10 





Clavicle 


12 


17 


8 

















Scapula 


69 


17 


8 





11 


7 








Humerus 


75 


67 


17 





11 


7 








Radius 


81 


50 


25 





11 


21 








Ulna 


75 


33 


25 


13 


11 


7 








Innominate 


69 


33 


8 





11 











Femur 


81 


33 


33 





22 











Tibia 


81 


33 


50 


13 


11 








:o 


Fibula 


81 


17 


42 





1 1 











SAMPLE SIZE 


16 


6 


12 


8 


9 


14 


10 


5 



Zagreb Paleopathology Symp. 1 988 



Skeletal lesions from a historic Afro-American cemetery • 121 



parisons are made to model life tables 
(Weiss 1973:115-186). The most diag- 
nostic feature of the Cedar Grove de- 
mographic profile is the large propor- 
tion (55.0%) of individuals younger 
than 15 years, which is identical to that 
(55.3%) produced by model life table 
15.0-45.0 (Weiss 1973:118). This 
model table is considered to be the best 
fit for the Cedar Grove demographic 
data. The computed life expectancy at 
birth for Cedar Grove is 14 years which 
is only slightly below the 15 years pre- 
dicted by the 15.0-45.0 model life ta- 
ble. The only major difference between 
Cedar Grove and this model life table is 
the much higher proportion of individu- 
als less than one year of age at Cedar 
Grove (27.5%) than predicted (5.4%) 
by the model table. However, when 
the large number of neonatal deaths 
(20.0%) are removed (i.e., skeletons 
aged at birth or younger than birth), the 



resulting figure (7.5%) is comparable. 
The Cedar Grove skeletal series is most 
remarkable for the extremely high rate 
of skeletal lesions; almost 90% of the 
entire sample exhibit at least one lesion, 
and the average is 12 per individual (to- 
tal lesions = 959). Five individuals are 
aged to younger than birth and probably 
were premature stillboms. Each of 
these exhibit active systemic periostitis 
indicating uterine infections which may 
be implicated in the premature births. 
Of the 1 1 neonates, 9 (81.8%) exhibit 
systemic active periostitis with addi- 
tional lesions as follows: 4 (36.4%) 
with active cribra orbitalia, 3 (27.3%) 
with active endocranial periostitis, and 
5 (45.4%) with periostitis of the ribs. 
One neonate has no lesions, while a 
second shows healed endocranial peri- 
ostitis. The 17 children between 3 and 
20 months of age display a lesion pat- 
tern comprising 23.5% craniotabes. 



Table 3. Percent healed osteolytic/prolifarative lesions by age in years 



Birth 


0.1-0.9 


1-5 


6-10 


11-29 


30-39 


40-50 


50+ 


Basiocranium 


























Calvarium 




















20 





Endocranium 


6 























Frontal 


6 

















10 





Orbit 








8 











10 





Maxilla 























20 


Mandible 














11 


14 








Cervical 


























Thoracic 











13 














Lumbar 











13 














Ribs 

















7 








Clavicle 














11 











Scapula 


























Humerus 


























Radius 


6 





8 





11 


7 








Ulna 


6 








13 





7 








Innominate 


6 























Femur 


6 











11 


7 


40 


20 


Tibia 


6 





17 


13 


56 


50 


90 


80 


Fibula 


6 





8 





33 


50 


80 


100 


SAMPLE SIZE 


16 


6 


12 


8 


9 


14 


10 


5 



58.5% active cribra orbitalia, 41.2% 
active sy.stemic periostitis, and 35.3% 
active endocranial periostitis. Al- 
though the most extensive lesion com- 
plex is systemic bacterial infection, two 
of the four cases of rib periostitis are not 
associated with other bone lesions. The 
pattern of childhood deaths is also of 
interest. The childhood deaths begin at 
3 months of age and slowly increase to 
a peak at 1 8 months where 4 1 . 2% of the 
subadult deaths occur. The adult skele- 
tal lesion pattern is far more diverse and 
exhibits a number of different lesion 
complexes. The lesion frequencies are 
high with 100% for the 15 males and 
86% for the 21 females. The frequency 
of healed cribra orbitalia (males 13.3%, 
females 0.0%) and remodeled porotic 
hyperostosis (males 33%, females 
23.8%) indicates prior experience with 
anemia. The periostitis rates of the 
lower limbs are high for both males 
(60.0%) and females (52.4%). Several 
of the lesions exhibit the morphological 
feature of subperiosteal hemorrhage. 
The frequencies of male spinal os- 
teophytosis (46.7%), Schmorl's nodes 
(33.3%), osteoarthritis of the major 
joints (33.3%), hands (13.3%), and feet 
(26.7%) are all relatively high. The 
females exhibit a similar pattern of spi- 
nal osteophytosis (33.3%), Schmorl's 
nodes ( 19.0%), and osteoarthritis of the 
major joints (28.6%), hands (19.0%) 
and feet (19.0%). 

Trauma is frequent with the males 
exhibiting 20.0% healed cranial frac- 
tures, 13.3% healed rib fractures, and 
one fatal bullet wound. Charac- 
teristically, the incidence of these le- 
sions is much lower for the females 
with only two (9.5%) cases of healed 
rib fractures and one fatal bullet 
wound. 

Having described the overall lesion 
pattern for the Cedar Grove skeletal se- 
ries, we presented in greater detail the 
proliferative lesions (i.e., periostitis, 
osteomyelitis, and osteitis) characteris- 
tic of bacterial infection. Table 2 pro- 
vides the percentage of active prolifera- 
tive lesions by age at death; Table 3 
provides the percentages of healed or 
healing proliferative lesions. It should 



Zagreb Paleaputhohiiy Symp. 19iiS 



122 • Jerome C. Rose and Philip Hartnady 



be noted that we combined age groups 
11-19 and 20-29 years to facilitate 
comparison by producing a sample size 
(9) approximately equal to the other age 
groupings. Table 2 shows that both the 
prematures and neonates (grouped to- 
gether as aged at birth) have a high fre- 
quency of systemic proliferative le- 
sions. Virtually every component of the 
skeleton is impacted: cranium, ribs, 
bones of the arm, pelvis, and bones of 
the leg. Of particular interest is the high 
rate of endocranial involvement (38%). 
The fact that these lesions are so exten- 
sive, even on those individuals aged 
younger than birth, strongly suggests 
that the infectious agent was contracted 
in utero. The patterning of lesions (i.e., 
distribution among the bones of the 
skeleton) remains relatively stable be- 
tween birth and 10 months, but then, 
with the exception of the cranium and 
clavicle, the frequency of infected 
bones declines. The fact that no healed 
cranial lesions are found on individuals 
of any age (Table 3) indicates that few 
or none of those neonates and children 
with cranial infections survived. For 
example, examination of infections of 
the calvarium (Figure 1) shows a de- 
cline with age and only two healed le- 
sions among those aged between 40 and 
49 years. This pattern is roughly similar 
for all bones of the skull. 

The postcranial skeleton shows a 
slightly different pattern. Active le- 
sions of the arm bones drop steadily 
from birth through 5 years and reoccur 
at sporadic low levels between 1 1 and 
39 years. This pattern can best be illus- 
trated by lesions of the radius (Figure 
2). The few healed infections of the arm 
can best be attributed to late-occurring 
infections and not to survivorship of the 
infected infants. The arm lesions sug- 
gest a bimodal pattern of origin with the 
first peak of active infections occurring 
before and at birth and the second oc- 
curring between 1 1 and 39 years. 

In contrast, the infectious lesions of 
the leg, especially the lower leg, show a 
trimodal distribution. Like the arm 
bones, the active lesions of the leg arc 
highest at birth, drop significantly be- 
tween birth and 10 months, exhibit a 



CEDAR GROVE CALVARIUM INFECTIONS 





100- 




90- 


c 
o 


80- 




70- 


0) 


60- 






^_ 


50- 


c 




o 


40- 


u 




0> 


30- 


a. 


20- 




10- 




0- 



Birth 



Figure 1. 



c 
o 



£ 

c 

c 
o 
u 

w 

o 

a. 



100 - 
90 . 
80 
70 - 
60 

50 H 
40 
30 

20 H 
10 




Birth 



P^ Active 
I I Healed 



II 



2/8 



0'/05 °VlO 'V29 3%9 



Age of Death 



"0/49 



60 • 



CEDAR GROVE RADIUS INFECTIONS 



t^^ Active 

! 1 Healed 



J 



XL 



AH 



JIL 



2/8 



'Vos 



06/10 



y29 



3%9 



"%< 



50- 



Age of Death 



Figure 2. 



second peak between one and five years 
(actually a modal age of 18 months), 
followed by a third consisting of an 
age-cumulative increase of healed le- 
sions. This pattern is best illustrated by 
the fibula (Figure 3). 

The ribs have been singled out for 
special attention because in one respect 
they are similar to the arm bones in dis- 
tribution, but different in that they are 
often not associated with lesions on 
other bones (Figure 4). Like the arm 
bones, active periostitis of the ribs 
drops between birth and five years and 
occurs at relatively low levels in adult- 



hood, with only one healed lesion in the 
entire sample. The majority of the early 
lesions can be attributed to systemic in- 
fection, but two children (one at 13 
months and the other at 20 months) dis- 
play no other infectious lesion. The 
three adults (one male and two females) 
with active rib infections also show no 
other active lesion. This distribution 
suggests that a separate pathological 
process is responsible. The fact that 
there is only one healed rib lesion pres- 
ent in the sample suggests that rib le- 
sions might be etiologically related to 
causes of death. 

Zagreb Paieopathotogy Symp- 1 98ft 



Skeletal lesions from a historic Afro-American cemetery • 123 





100- 




90- 


c 




o 


80- 


t> 


70 - 


0) 




c 


60 - 


c 


50 - 


o 


40 - 






» 


30 - 


a. 






20 - 




10 - 
- 



L 

ijIL 



CEDAR GROVE FIBULA INFECTIONS 

^^ Active 
I I Healed 



JIL 



m 



Birth 



•2/8 



°V05 



06/10 



729 



3%9 



"OAg 



50 ^ 



Age of Death 



Figure 3. 



CEDAR GROVE RIB INFECTIONS 





100- 


c 
o 


90 - 
80 - 


£ 


70 - 
60- 


c 
o 
u 

1 


50 - 

40 - 
30 - 




20 - 




10 - 



g^ Active 
I I Healed 



^ r^n m 



Birth 2/8 oVo5 °^Ao 'Vag 3%9 "0/49 50- 

Age of Death 



Figure 4. 



Discussion 

Two interrelated goals are pertinent to 
this analysis of the Cedar Grove demo- 
graphic and paleopathological data. 
The first is establishing the contribution 
which these data can make to improv- 
ing our understanding of Afro-Ameri- 
can life after Reconstruction, at least 
for a part of southwest Arkansas. The 
second goal is demonstrating with a 
specific example the utility of palcodc- 
mographic and paleopathological anal- 
yses by comparing their results with 

Zagreb Paleopathology Symp. 1988 



those obtained from historical analysis 
of documentary data. 

Since there is a dearth of specific 
data concerning postemancipation diet, 
dietary information from the better doc- 
umented slavery period will first be 
summarized. Based on available docu- 
mentary data the following dietary defi- 
ciencies have been postulated for south- 
em slaves; the 70-77% lactose intoler- 
ance rates of Afro-Americans con- 
tributed to low milk consumption and 
calcium deficiency (Kiplc and Kiplc 
1977:290; Kiple and King 1981:72); 



the low niacin content of the corn and 
pork diet resulted in pellagra (Gibbs et al. 
1980:205; Kiple and King 1981:127); 
the low bioavailability of iron in a corn- 
based diet combined with frequently in- 
herited Afro-American blood abnor- 
malities (e.g., sickle cell) to produce 
frequent anemia (Kiplc and Kiplc 1977: 
285; Kiple and King 1981:97); low 
milk consumption combined with dark 
skin produced vitamin D deficient 
rickets (Kiple and King 1981:195; Ki- 
ple and King 1981:93); and the low 
amino acid proportions of tryptophan, 
lysine, and methionine in both com and 
pork proteins contributed to protein 
malnutrition (Kiple and Kiple 1977: 
287). Other dietary inadequacies such 
as thiamin deficiency causing beriberi 
(Kiple and King 1 98 1 : 1 1 9) and magne- 
sium deficiency which lowers resis- 
tance to infection (Kiple and King 
1981:98) have been mentioned. 

For the postemancipation period 
there are only generalizations from 
various locations throughout the Amer- 
ican South to work from. Donald (1952: 
47) indicates that, on the whole, the 
diet of South Carolina Afro- Americans 
was coarse and consisted of hominy, 
combread, fat bacon, some pork, 
coffee , rice, molasses, and occasional 
vegetables. Similarly, Kiple and King 
( 198 1 : 1 89) state that the diet went from 
bad under slavery to worse under free- 
dom. Within the Cedar Grove locale it 
is not certain exactly what dietary 
changes occurred after emancipation. 
The 1865 contract negotiated by the 
Freedmen's Bureau between the former 
slaves and Sentell family called for the 
provision of a wage, rations, housing, 
and one acre of land per household in 
exchange for labor on the plantation 
(Watkins 1985:12). At that point in 
time, it seems that the Afro-American 
diet was still being dictated by the land- 
owner. For example, under the terms of 
the above-mentioned contract, no live- 
stock except poultry could be owned 
(Watkins 1985:12). This surely would 
have limited the supply of meat in the 
diet and prevented the former slaves 
from using animal power to raise food 
on their one acre of allotted land. 



124 • Jerome C. Rose and Philip Hartnady 



This contract labor system soon 
came to an end and the large plantations 
were broken up into individual allot- 
ments, farmed by the Afro-Americans 
under a sharecropping arrangement 
(i.e., a portion of all crops was turned 
over to the landowner). The system of 
advancing loans for seed and supplies, 
which was commonly intnxiuced through- 
out the South, usually served to keep 
the sharecroppers poor and in debt to 
the landowners and merchants (Chris- 
tensen 1958). Conditions deteriorated 
further in 1888 when a rapid decline in 
cotton prices left all southern Arkansas 
farmers poor and in debt to the stores 
(Graves 1967:30). A further disaster 
occurred in 1905 when the boll weevil 
arrived in southeast Arkansas and vir- 
tually wiped out the cotton crops, the 
major source of cash income (Sylva 
1981:52). These deteriorating agrarian 
conditions stimulated the Euro-Ameri- 
can backlash which wiped out virtually 
all the social gains of the Reconstruc- 
tion period. The process of segregation 
and political disenfranchisement began 
with the passage of new discriminatory 
voting laws and the first Arkansas seg- 
regation law, the separate coach act, in 
1891 (Graves 1967:61-94). These po- 
litical and social changes, in combina- 
tion with the farm price crisis, should 
have seriously and adversely impacted 
Afro-American diet and health in the 
Cedar Grove area. 

Sylva identifies a decline in the Afro- 
American population in southwest 
Arkansas during this period and at- 
tributes it to outmigration ( 1 98 1 : 1 6). In 
contrast, Farley observes a national 
trend of significant slowing of the Afro- 
American population growth between 
1880 and 1940 (1970:3). He notes that 
Afro-American women who began 
childbearing before 1850 and survived 
until menopause produced an average 
of seven children and less than \Q% of 
these women produced no children. 
Women born between 1900 and 1920 
not only had the lowest fertility before 
or since, but 30% never had a child and 
those that did had fewer (Farley 1970: 



3). These data suggest that a biological 
crisis occurred for the entire Afro- 
American population at the turn of the 
century. This trend was so noticeable 
that Holmes (1937) prepared a mono- 
graph predicting the disappearance of 
Afro- Americans. 

The population decline is to be at- 
tributed not only to decreased fertility, 
but also to greatly increased mortality. 
Urban Afro-American life expectancy 
at birth in 1900 was 33 years for males 
and 35 years for females (Farley 
1970:61). In 1900 the Afro-American 
mortality rate was 3.02%, nearly twice 
that of Euro-Americans with 1.73% 
(Holmes 1937:40; Kiple and King 
1981:188). This high mortality rate is 
observed at all demographic levels. The 
non-Euro-American infant death rate 
was 275 per 1000 live births (Farley 
1970:212). The non-Euro-American 
maternal mortality rate in 1920 was still 
13 per 1000 live births, while the neo- 
natal death ratio was 72 per 1000 live 
births (Farley 1970:209). Physicians 
commonly noted that the Afro-Ameri- 
can stillbirth rate was two to three times 
higher than Euro- Americans ( Kiple and 
King 1981:188). Farley, in an attempt to 
explain both the high stillbirth rate and 
decreased fertility, suggests venereal 
disease, citing as evidence a 20% infec- 
tion rate among Afro-American females 
and a 1900 infant death rate of 2.7 per 
1000 live births due to congenital syph- 
ilis (1970:12). 

Donald's examination of the recorded 
disease patterns shows that Afro- Amer- 
icans suffered a higher mortality rate 
than Euro-Americans from all diseases 
except cancer (1952:162). Using the 
1900 census, Farley (1970:70) lists the 
most frequent causes of Afro- American 
deaths as tuberculosis, pneumonia, ner- 
vous disorders, diarrhea, typhoid fever, 
and malaria. Both tuberculosis and 
pneumonia were major killers of Afro- 
Americans (Kiple and King 1981: 188) 
with Afro-American tuberculosis rates 
being reported as three times higher than 
Euro-Americans (Holmes 1937:76). 

The data and interpretations pre- 



sented above are derived primarily 
from the national census and pertain to 
the areas of registration. They may or 
may not describe the situation in south- 
west Arkansas nor, in particular, the 
community of Cedar Grove. Keeping in 
mind this limitation of the data, they are 
compared and contrasted with those 
collected from the Cedar Grove skeletal 
sample. 

Using the cross-sectional skeletal de- 
mographics as a true birth cohort allows 
thecalculationof mortality rates. Using 
the ratio of skeletons aged to less than 
one year to total skeletons produces an 
infant mortality rate of 27.5%, which is 
identical to the national non-Euro- 
American infant mortality of 27.5% 
cited by Farley ( 1 970:2 1 2) for this same 
time period. Using the ratio of skel- 
etons aged younger than birth to total 
skeletons produces an estimated still- 
birth rate of 6.2%, which is close to 
Farley's (1970:209) 1920 national non- 
Euro-American rate of 7.2%. Although 
life expectancy at birth obtained from 
the skeletal life table (14 years) is far 
below the 33 years for males and 35 
years for females reported by Farley 
(1970:61), the average adult skeletal 
ages at death (males 41.2, females 
37.7) are reasonably close to these 
national statistics. The entire Cedar 
Grove paleodemographic profile calcu- 
lated from the skeletal data is in excel- 
lent concordance with the national sta- 
tistics and the historic reconstructions. 
These results suggest not only that pal- 
eodemography can be used reliably, but 
also that the Cedar Grove community 
followed the national trends of in- 
creased mortality and decreased fertil- 
ity. In other words, the Cedar Grove 
community was highly stressed during 
the post-Reconstruction period. 

There is abundant evidence of di- 
etary deficiencies in the Cedar Grove 
skeletal sample. The high rate of active 
cribra orbitalia among children (58%) 
and the rates of healed cribra orbitalia 
and porotic hyperostosis among adults 
(males 33%, females 24%) indicate ex- 
tensive anemia. Most of the anemia can 



Zagreb Paleopathology Symp. 1988 



Skeletal lesions from a historic Afro-American cemetery • 125 



be attributed to iron deficiency result- 
ing from a reliance upon com and a lack 
of red meat in the diet, as suggested by 
the historical literature (Kiple and Ki- 
ple 1977:285). Some of these lesions 
can be attributed to sickle cell, but this 
genetic trait should account for only a 
small percentage of the observed cases 
(Ortner and Putschar 1981:254-258). 
The 24% craniotabes for children dying 
between 3 and 20 months can be at- 
tributed to vitamin D deficient rickets, 
associated with the historically postu- 
lated low milk consumption caused by 
a high rate of lactose intolerance com- 
mon among Afro-Americans, and the 
documented scarcity of cattle among 
the sharecroppers (Kiple and Kiple 
1977:290; Kiple and King 1981:72). At 
least some of the extensive childhood 
periosteal deposits and the ossified 
hematomas among the adults may be 
attributable to vitamin C deficiency 
(Ortner and Putschar 1981:271-272) 
caused by a lack of fruits and vegeta- 
bles in the diet. These high rates of le- 
sions specific for dietary deficiencies 
indicate a very inadequate diet in the 
Cedar Grove community between 1 890 
and 1927. 

The high frequency of active sys- 
temic periostitis found among both pre- 
matures and neonates suggests the exis- 
tence of at least one dominant disease. 
Farley's (1970:12) suggestion of con- 
genital syphilis can be tested with the 
skeletal data. Steinbock (1976:98-99) 
describes early congenital syphilis as 
occurring between birth and three to 
four years, being associated with uni- 
versal bone changes which include peri- 
ostitis and diaphyseal osteomyelitis, 
and having a mortality of at least 50%. 
Ortner and Putschar (1981:198) state 
that congenital syphilis leads to early 
fetal death, delivery of a premature or 
mature diseased stillborn fetus, or de- 
livery of a living infected newborn. 
They further state that syphilitic perios- 
titis can have begun in utero and be 
present at birth (1981:198). Steinbock 
(1976:100-101) states that cranial os- 
teitis can impact both cranial tables. 



The association of endocranial new 
bone formation and long bone peri- 
ostitis found in a prehistoric Native 
American skeletal sample has been at- 
tributed to one of the treponematoses 
by Cook and Buikstra (1979:658). 

All five Cedar Grove skeletons with 
dental ages younger than birth (seven to 
eight fetal months) exhibit systemic 
periostitis involving virtually every 
bone. All but 2 of the 1 1 individuals 
dying at birth exhibit systemic perios- 
titis, while one of the exceptions has 
only endocranial periostitis. Of the 18 
deaths between three months and 3.5 
years, 48% exhibit systemic periostitis. 
Taken together, the high frequency of 
prematures with systemic periostitis, 
the high neonatal mortality associated 
with active systemic periostitis, and the 
absence of systemic periostitis after 3.5 
years all suggest congenital syphilis as 
the dominant disease entity. This diag- 
nosis is further strengthened by the 
presence of Hutchinson's maxillary in- 
cisors on one 10-year old. These four 
maxillary incisors match the classic de- 
scription of Hutchinson's defect includ- 
ing notching, barrel shape, and con- 
vergent lateral margins (Steinbock 
1976:107). The diagnosis as Hutchin- 
son's incisors was also confirmed by 
histological examination (Marks 1984). 
If the diagnosis of widespread con- 
genital syphilis is correct, then the 
characteristic lesions of venereal syph- 
ilis should also be evident in the adult 
sample. The ranking by frequency of 
{jeriostitis among the older individuals 
is tibia, fibula, radius, ulna, and femur. 
This ranking is fairly consistent with 
that reported for venereal syphilis 
(Steinbock 1976:112). Of particular 
importance is the high frequency of 
periostitis of the arm bones at Cedar 
Grove, which is a fairly uncommon lo- 
cation for other infectious diseases and 
consistent with the presence of venereal 
syphilis (Steinbock 1976:112). Absent 
from Cedar Grove are the characteristic 
cranial lesions of syphilis, the saber 
shins, and the extensive osteomyelitis 
of the tibiae (Ortner and Putschar 



1981:201-218; Steinbock 1976:108- 
136). Despite the absence of un- 
disputed acquired syphilis among the 
adults, the diagnosis of congenital 
syphilis as the major cause of still- 
births, high neonatal mortality, and 
widespread systemic infection appears 
very reasonable. 

A second pathological phenomenon 
is indicated by the fact that, while the 
frequency of lesions in all other bones 
continues to decline, the tibia, fibula, 
and endocranium show a relatively 
large increase between one and five 
years (Tables 1 and 2). In fact, 58% of 
the deaths between one and five years 
occur at 18 months of age. The 18- 
month modal age at death, a common 
age of weaning, combined with an in- 
crease in infections of the tibia and 
fibula is highly suggestive of weanling 
diarrhea (Scrimshaw et al. 1968:216- 
260). This syndrome is characterized 
by low-protein weaning diets which 
contribute to lowered resistance to in- 
fection and initiate a cycle of diarrhea 
and infectious disease. The presence of 
protein malnutrition resulting from 
amino acid deficiencies associated with 
corn- and pork-dominated diets has 
been noted in the historic literature (Ki- 
ple and Kiple 1977:287). 

The presence of rib periostitis that is 
not associated with systemic infection 
has been previously identified in two 
children ( 1 3 and 20 months), one adult 
male, and two adult females. The loca- 
tion of these lesions on the medial sur- 
face of the rib body and their gross ap- 
pearance conform with the lesions 
identified by Kelley and Micozzi 
(1984) as being associated with pulmo- 
nary tuberculosis among cadaver speci- 
mens from the same time period as 
Cedar Grove. As tuberculosis is identi- 
fied as the leading cause of death 
among Afro-Americans at the turn of 
the century (Farley 1970:70; Holmes 
1937:76), assigning 6% of the Cedar 
Grove deaths to this disease is appropri- 
ate. This is not to say that the rib lesions 
associated with other infected bones are 
not also attributable to tuberculosis, but 



Za/treh Palenpalhology Symp. J9SS 



126 • Jerome C. Rose and Philip Hartnady 



the 6% is a conservative estimate of the 
frequency of tuberculosis. 

The final lesion complex to be dis- 
cussed is the age-cumulative increase 
in healed infections of the lower leg. 
The location of the tibia just below the 
skin makes it vulnerable to frequent in- 
troductions of bacteria from relatively 
inconsequential accidental wounds 
(Ortnerand Putschar 1981:132). Thus, 
the frequency of tibia infections should 
increase under conditions of reduced 
resistance to disease where the reduc- 
tion of the body's defense mechanisms 
permits the infectious agents to become 
established. Periostitis of the tibia is 
frequently found in archeologically 
derived skeletal collections (Ortner 
and Putschar 1981:131; Steinbock 
1976:82). in contrast, we have found 
periostitis of the fibula to be propor- 
tionally less frequent in prehistoric 
American skeletal samples (i.e., 50% 
or less than the tibia rate) and interpret 
the infections of the fibula as being as- 
sociated with either major leg trauma or 
spread of infection from the tibia. 
Thus, increases in fibula infections can 
be used to indicate a reduction in dis- 
ease resistance. The age-specific fre- 
quencies of adult healed tibia infections 
range between 56 and 90%, while the 
fibula rates range between 33 and 100% 
(Table 3). The virtual absence of active 
lower leg infections indicates that these 
lesions were not associated with the 
cause of death, but represent previous 
episodes from which the individuals re- 
covered. Both the high frequency of 
tibia and fibula periostitis and the con- 
cordance of rates between the two 
bones suggest diminished disease re- 
sistance among the people of Cedar 
Grove. This interpretation is consistent 
with the historical literature which sug- 
gests poor diet and high stress for Afro- 
Americans in the post-Reconstruction 
South. 



Conclusions 

In this analysis of the Cedar Grove in- 
fection data we have attempted to 
achieve two goals: first, to improve our 
understanding of Afro-American dis- 
ease patterns in the post-Reconstruc- 
tion period of southwest Arkansas, and 
second, to demonstrate that paleo- 
demographic and paleopathological 
analysis can provide interpretations 
compatible with historic interpreta- 
tions. The Cedar Grove skeletal de- 
mography is in excellent concordance 
with the census data. There was high 
infant mortality (27.5%), high frequen- 
cy of stillbirths (6.2%), and high adult 
mortality with average ages of death at 
41 years for males and 38 years for 
females. Skeletal evidence for dietary 
deficiencies including iron, vitamins D 
and C, and protein are in agreement 
with the historical reconstructions. 

The distribution of proliferative le- 
sions by affected bones of the skeleton 
and age indicates the presence of four 
major disease clusters. The systemic 
infections among the neonates indicate 
the presence of widespread congenital 
syphilis. Although the classic stigmata 
of venereal syphilis are not found 
among the adults, the presence of le- 
sions on the bones of the arm is sugges- 
tive. The peak mortality at 18 months 
and an associated increase in prolifera- 
tive lesions indicate the presence of the 
weanling diarrhea syndrome and, by 
implication, protein deficiency. A dra- 
matic age-cumulative increase in 
healed lesions of the tibia and fibula 
indicates continued adult malnutrition 
and high overall stress loads. The fre- 
quent rib infections are consistent with 
a high frequency of pulmonary tuber- 
culosis. All of these conclusions are 
compatible with the interpretations pro- 
duced by historical analysis of the doc- 
umentary data. 



Acknowledgments 

Financial support for the Cedar Grove 
Cemetery excavation and analysis was 
provided by the U.S. Army Corps of 
Engineers, New Orleans District, to the 
Arkansas Archeological Survey and the 
senior author. 



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Summary of audience discussion: The 
frequency of infections in this reported 
group is four to five times higher than that 
found in the preceding slave period. Histor- 
ical literature from the 1890-1930 period 
indicates biologists found Afro-Americans 
in such a severe state of demographic dis- 
equilibrium that they predicted their extinc- 
tion in America by 1950. It may have been 
their participation in the public assistance 
programs of the 1 930s that reversed the sit- 
uation. 

The endoeranial periostitic lesions are in- 
triguing since, if they were infectious, it is 
not easy to postulate how fatal meningitis 
was avoided for a period long enough to 
permit the observed osseous response. One 
possibility may be that the lesion was a re- 
flection not of acute, pyogenic disease but 
rather of intrauterine treponematosis. This 
consideration is based on the slender evi- 
dence of observing that all cases were in 
neonates or feti and that Hutchinson's teeth 
evolve in a milieu of spirochete-infected 
tissue. 

While it might be intriguing to view this 
as a population healthy enough to resist ma- 
jor infections, their calculated infant mor- 
tality and stillbirth rates are identical with 
the disastrous contemporary demographic 
statistics, indicating that this population 
was not healthier than others, but instead 
was in a devastatingly unhealthy state. 



Zagrrb Pateopaihology Symp. t988 



Paleopathological study on 
infectious diseases in Japan 



Takao Suzuki 



1 oday's clinical features of infection including its inci- 
dence, symptoms, course, and pathological morphology in 
living tissues have been dramatically changed by the wide- 
spread use of antibiotics after World War II. Inflammatory 
changes commonly found in archeological skeletal remains 
provide good evidence of the vivid reaction of extrinsic in- 
sults to the bone. However, it is not necessarily easy to diag- 
nose the precise, causative disease producing such inflam- 
matory changes based on the morphological features. On this 
point, Putschar ( 1966:59-60) stated as follows: 

Inflammatory bone lesions pose much more serious diag- 
nostic problems and therefore deserve more detailed discus- 
sion. Periosteal deposition of bonewith or without 
thickening and architectural change of the underlying cor- 
tex of the diaphysis of long bones is probably the most 
common inflammatory lesion found in prehistoric material. 
The lesion often appears to be in a chronic or healed stage, 
and it is frequently impossible to ascertain whether the 
changes arc traumatic or infectious in origin. 

In the present study, inflammatory lesions appearing in ar- 
cheological skeletal materials have been examined mac- 
roscopically and categorized in order to use them as an in- 
dicator of the health status in earlier populations. The 
procedure of this study deals with the classification of the 
inflammatory lesion in terms of gross morphology, and its 
limitations and availability in reconstructing a pattern of 
health. Even the equivocal lesions existing between non- 
specific and specific disease, which may be an unavoidable 
problem in paleopathology, have been considered as a part of 
the available information for epidemiological analysis. 

In this context secular changes regarding the frequency of 
infectious diseases in the skeletal populations in Japan have 
been examined and interpreted with respect to biocultural 
background. Among specific diseases, tuberculosis and 
syphilis have been extensively studied. These two diseases 
are viewed from the standpoints of origin, dissemination and 
prevalence in the Japanese archipelago. 



128 



Geographic, tiistoric, and archeological 
background 

The Japanese archipelago is made up of four main islands 
(Honshu, Shikoku, Kyushu, and Hokkaido) which together 
with more than 4000 smaller islands lie off the east coast of 
Asia showing a crescent shape. The climate of these islands, 
ranging from subfrigid to subtropic, is mostly a temperate 
and oceanic type with four distinct seasons. More than 60% 
of the land is mountainous, and most of this is covered with 
forests. All of these environmental factors may have a con- 
nection with the diseases of the inhabitants as well as the 
ecological, biological, and sociological factors. 

The origin of the Japanese people is not altogether clear 
with respect to location and time. However, paleolithic stone 
implements suggest that their ancestors inhabited these is- 
lands for more than ten thousand years. The beginning of the 
Japanese neolithic period, Jomon, is still controversial and 
unproven to many anthropologists. However, this prehistoric 
period lasted at least several thousand years, and ended at 
about the third century B.C. The main subsistence strategies 
during the Jomon period were hunting, fishing and gathering. 
The Jomon people made a lot of clay utensils including pot- 
tery characterized by cord-marking (Jomon). The Jomon 
people were buried under shell mounds which have protected 
their skeletal remains from volcanic and acid soil. 

During the Eneolithic period, Yayoi (third century B.C. to 
about third century a.d.), which followed the Jomon period, 
a large number of immigrants migrated to the western part of 
Japan via the Korean Peninsula. Immigrants mixed with the 
Jomon people who were aboriginals in this area. It was dur- 
ing this period that the Japanese mastered the art of rice 
cultivation, began to use metal implements, and set the fun- 
damental pattern of Japanese tradition and life. From the 
paleopathological point of view, some new infectious dis- 
eases seem to have been transmitted from the Asian continent 
to Japan with such a huge numberof immigrants at that time. 
According to the traditional history of Japan, the migration 

Zagreb Paleopathology Symp- 1988 



I 



Paleopathological study on infectious diseases in Japan • 129 



from the Korean Peninsula continued until around the eighth 
century a.d. Japanese living in western areas were likely to 
be atTected by such migrants physically, although the Ainu in 
Hokicaido seemed to remain unmixed (Hanihara 1985). 
Therefore, the influence of the admixture which took place 
after the Yayoi period is still evident in western Japan. How- 
ever, the eastern Japanese maintain some characteristics 
which are similar to the Ainu to a greater or lesser extent 
(ibid.). 

After consolidation of Japan into a single nation in the 
fourth century, successive emperors strengthened the foun- 
dation of the country by introducing various aspects of conti- 
nental learning and culture. These included the Chinese 
writing system, ideology (Confucianism) and religion (Bud- 
dhism). In particular. Buddhism recommended cremation, 
and after the protohistoric period people did not make shell 
mounds as a burial site, so that complete skeletal remains 
belonging to the protohistoric period are ditficult to find 
except for some special burial ca.ses. 

Materials 

The skeletal materials used in this study were from collec- 
tions of various periods and sites housed in several univer- 
sities. Only adult skeletons were examined for their patho- 
logical changes because of the abundance in quantity and 
quality. Four major skeletal series can be considered as the 
core of this study: 

1 . The Jomon skeletal series consisted of 272 individual 
skeletons from eight sites (seven from shell mounds and one 
from a cave site). Among them, six skeletal series (Hobi. Ko, 
Nakazawahama, Ubayama, Kasori, Yosekura) are housed in 
the Department of Physical Anthropology of the University 
Museum. The University of Tokyo, and they are registered 
and catalogued by Endo and Endo ( 1979). Two other Jomon 
skeletal series from Tsukumo and Yoshigo are housed in the 
Department of Physical Anthropology, Kyoto University. 

2. The Edo skeletal series consisted of 308 femora and 253 
tibiae housed in the Department of Physical Anthropology of 
the University Museum, The University of Tokyo. Whole, 
individual skeletons of the Edo period (latest medieval, ear- 
liest modem) could scarcely be excavated because most buri- 
al sites of this period, particularly in Edo (old Tokyo) city, 
were secondary and reburied sites. Therefore, the skeletal 
materials which were from five Edo sites (Unko-in,Joshin-ji, 
Fudo-ji, Hoden-ji and Edogawa-bashi) could not be identi- 
fied as to age, sex, or individual. Besides the long bone 
material of femora and tibiae, 923 skulls of the Edo period 
which have already been studied by the author with respect to 
cranial syphilis (Suzuki 1984a) were used for this study. 

3. The Ainu skeletal series consisted of 178 individual 
skeletons, and were from two northern islands: Hokkaido 
and Sakhalin. These skeletal materials, believed to be from 
the latest medieval and earliest modem Ainu, correspond to 



the Edo period and were collected by Koganei in Hokkaido 
(Koganei 1894) and by Kiyono in Sakhalin (Kiyono 
1943,1949). The materials from the Hokkaido Ainu, called 
"Koganei collection," are housed in the Department of Anat- 
omy of the University Museum, The University of Tokyo. 
The materials of Sakhalin Ainu, a part of the "Kiyono collec- 
tion," are housed in the Department of Physical Anthropol- 
ogy, Kyoto University. The detailed paleopathological stud- 
ies on these major Ainu skeletal series have already been 
conducted and reported by the author (Suzuki and Ikeda 
1981; Suzuki 1984b, 1985b). 

4. The Meiji Japanese (early modem) skeletal series con- 
sisted of 113 whole, individual skeletal materials from the 
Kanto area (central part of Honshu). These materials are now 
housed in the Department of Anatomy, Sapporo Medical 
College. Their demography (sex, age and birthplace) is well 
recorded. These individuals ranged from 20 to 80 years old. 
They died between 1927 and 1944. Some osteological and 
physical anthropological studies on this series have been car- 
ried out by several authors (Mitsuhashi 1958; Wada 1975; 
Hashizaki and Kaneko 1979; Higuchi 1983). 

The locations of the major sites of these four skeletal series 
are indicated in Figure 1 and detailed contents of individuals 
and skeletal parts of these series are listed in Table 1 . 

Furthemiore. in addition to these four major skeletal series 
a few cases exhibiting interesting pathological conditions 
were used in the study. These special cases will be described 
as to the sources and data in each case. 

Methods 

GROSS OBSERVATION 

Pathological changes appearing on the skeleton from Jomon 
to modem Japanese skeletal series were examined by gross 
observation and, in most cases, by x-ray film. Neither a 
histological nor a microscopic study has been carried out. 

The examination was carried out only on adult skeletal 
remains, because the subadult skeletons were few and most 
of them were so badly damaged that the identification and 
pathology were difficult to ascertain. The skeletal parts ob- 
served in this study included skull, sternum, and vertebral 
column, and also limb girdle bones such as the scapula, 
clavicle, and pelvis, as well as long bones of the extremities 
including humerus, radius, ulna, femur, tibia, and fibula. 
Small bones of the hand and feet were excluded as well as 
fragmented ribs. From the Edo period only skull, femur, and 
tibia were examined because of the commingled state caused 
by reburials. 

Lesions appearing in both the maxilla and mandible 
caused by periodontal diseases were excluded in this study. 
Those inflammatory changes, though frequently appearing 
in archeological specimens with abscess formation, should 
be classified into another category, such as "lesions of jaws 
and teeth" (Ortner and Putschar 1981:436-456). 



Zagreb Paleopathology Symp. 1988 



130 • Takao Suzuki 



SAKHALIN 



CHINA 




JAPAN 



Figure 1. Major archeological sites from which skeletal 
remains were used in this study. Jomon sites (small black 
circles): a. Nakazawahama; i>, Ubayama;r, Kasori;^/. Hobi; 
e. Yoshigo;/, Ko; g. Tsugumo; h, Yosekura. Yayio, Kofun. 
and Medieval sites (large black circles): a, Katsuyama-Tate; 
b. Unoki-Kofun; c. Shiroyama-Kofun; d, Zaimokuza; 
e. Ichino-Torii. Edo (old Tokyo) sites: open squares. Early 
modem Japanese sites: open triangles. Ainu sites: open cir- 
cles. 



TAXONOMY OF INFLAMMATORY CHANGE IN THE BONE 

The periosteum, cortex, and medulla of bone have such a 
close relationship that infectious change occurring in one part 
of the bone cannot help but influence another part. In dry- 
bone specimens, almost all infections usually can be 
classified as either osteomyelitis or periostitis. Periostitis is 
defined as periosteal reactive bone changes with irregular, 
fine-porous and spongy deposition located only exterior to 
the cortex with no involvement of the underlying cortex. The 
most common feature of such periosteal reaction tends to be 
"plaquelike" periostitis (Figure 2) which may show various 
degrees of severity or stages, as stated by Stothers and 
Metress (1975). Osteomyelitis is defined as infiammatory 
changes spread through the medullary cavity and, in many 
cases, the cortical bone. The most common feature of sup- 
purative osteomyelitis is characterized by sequestrum, invol- 
ucrum, and cloacal formation, particularly in the long bones 
(Figure 3). As is well known, there is an uncommon form of 
chronic osteomyelitis characterized by remarkable scleros- 
ing of the lesion without any cloacal openings, which can 
usually be seen in the shafts of the lower extremities of adults 
(Figure 4), the so called "sclerosing osteomyelitis of Garre." 
From the viewpoint of modem clinicopathology, inflam- 
matory changes in living tissue are usually classified into two 
categories: nonspecific inflammation and specific inflamma- 
tion. This classification is also available in the paleopatho- 
logical field and actually has been used by some authors 
(e.g., Putschar 1966:60; Stothers and Metress 1975; Stein- 
bock 1976:60,86; Ortner and Putschar 1981:104,129-138; 
Goodman et al. 1984). In this study, therefore, inflammatory 
bone changes are also categorized into two groups, non- 
specific and specific bone inflammation. In the dry-bone 
specimen, nonspecific inflammation can be defined as an 



Table l. Skeletal material studied 










Period Total Sex 
no. 


Skull 


Vertebra 


Femur 

R L 


Tibia 
R L 



Joson 


272 


M 


163 


(prehistoric) 




F 


109 


Edo Japanese 


923 


M 


636 


(17lh-19thC. A.D 


) 


F 


287 


Meiji Japanese 


113 


M 


86 


(19th C. A.D.) 




F 


27 


Ainu 


178 


M 


102 


(early modern) 




F 


76 



923 



246 97 165 167 158 166 



172 136 139 114 



106 113 113 ID 113 113 



173 67 99 101 94 100 



Zagreb Paleopathology Symp. 1988 



Paleopathological study on infectious diseases in Japan • 131 




Figure 2. Schematic representation of 
moderate "plaquelike" periostitis and a 
case from Jomon site (Tsukumo siiell- 
mound). 




Figure 3. Schematic representation of ad- 
vanced chronic osteomyelitis with seques- 
trum, involucrum, and cloaca formation 
(MacCallum 1920). 

Zaf;reb Paleopathology Symp. 1988 



Figure 4. Sclerosing osteomyelitis of Garre from modem Japanese skeletal mate- 
rial: a. pathological (right) and nonnal (left) bone specimen; b. x-ray film. 



ordinary inflammatory reaction represented mainly by peri- 
ostitis with plaquelike bone deposition and, in the advanced 
case, by osteomyelitis. On the other hand, specific inflam- 
mation can be characterized by a peculiar granulomatous 
lesion even in the dry bones which may be detectable in gross 
examination. Actually, in the typical/advanced cases of tu- 
berculosis and syphilis, their inflammatory changes can be 
diagnosed by characteristic morphology and peculiar dis- 
tribution of the lesion in the skeleton. In some cases, of 
course, geographical and epidemiological information 
should be considered in order to evaluate the bone lesion and 
differentiate between possible diseases which affect the skel- 
eton in a similar fashion (Buikstra 1976). 

However, in the case showing slight inflammatory bone 
change or even in the advanced changes with ordinal perios- 
teal reaction, it is not always possible to difterentiate these 
two categories with certainty. Only typical and demonstrable 
cases showing peculiar morphology caused by specific infec- 
tion can be diagnosed in the dry-bone specimens. In other 
words, it is quite natural that overlapping between non- 
specific and specific inflammatory change, particularly in 
the early stage of bone infection, would occur in archeologi- 
cal specimens. Therefore, the etiology of periostitis, which is 
very common in archeological specimens, cannot always be 
identified. This is one of the reasons why periostitis has often 
been treated as an independent entity in paleopathology. On 
this problem, Ortner and Putschar (1 98 i : 1 3 1) stated the fol- 
lowing: 



132 • Takao Suzuki 



/ 



\ 



Nonspecific Inflammation 



\ 



Periosiiils 

exsudative 

Periostitis 

purulenta 
Periostitis 

fibrosa 



/ 



Osteomyelitis suppurative 

sequestrum 

involucrum 

cloaca lormation 



Specific Inflammation 



/ 



Periostitis 
tuberculosa 



\ 



Periostitis ossificans 
"plaquelike" deposition 
tfiickening of exterior 
smaller/larger pores 
uneven hypervascularity 




\ 



Spondylitis tuberc 
(kyphosis, etc ) 

Dactylitis tuberc 
(spina ventosa) 



Osteomyelitis 




k- 



Independent entity 

in 
paleopathology 



Periostitis 
syphilitica 



y 



/ \ 

Caries sicca in the skull 
(stellate scars, etc.) 

Gummatous 
periost - osteomyelitis 
(snail ■ track pattern, etc ) 

y 



Figure 5. Lesions in specific and nonspecific inflammatory conditions of bone. 



The main reason for this difference between clinical and 

paleopathology is that many of the periosteal reactions may 
be part of the expression of a specific disease process, 
which can be identified in a living patient, whereas in ar- 
cheological specimens the pathological characteristics nec- 
essary to make a specific diagnosis are not available. This 
would have the effect of increasing the frequency of non- 
specific periostitis in archeological skeletal series. 

Such a special situation of peiiostitis in paleopathology is 
shown in Figure 5. Thus in the present study, due to the 
possible admixture of these two kinds of infections among 
the archeological specimens, the author cannot help but deal 
with all inflammatory changes in the bone as nonspecific 
inflammation, excluding only the typical/demonstrable case 
showing specific changes of bone tuberculosis and syphilis. 

Results 

Gross examination of the infectious changes was conducted 
on four skeletal series: the Jomon (prehistoric) series includ- 
ing 272 individuals, the Ainu series of 178 individuals, the 
Meiji (early modem; antibiotic era) Japanese series of 1 13 
individuals, and the Hdo (latest medieval/earliest modem) 
Japanese series consisting of 923 skulls, 308 femora, and 253 
tibiae. The data on cranial syphilis of the Edo series was 
quoted from the previous study carried out by the author 
(Suzuki 1984a). 



FREQUENCY OF THE INFECTIOUS LESION. The TCSUltS are 

shown in Table 2. The highest frequency can be seen in the 
Meiji Japanese series and the lowest was in the Jomon series. 

SEX DIFFERENCES OF THE FREQUENCY. ExCCpt for the Edo 

Japanese series, the number and total frequency of infectious 
lesions in both sexes are shown in Table 3. There is no statis- 
tical significance between the male and female frequencies 
(X^ = 0.267 < p(O.Ol)]. The frequency of cranial syphilis in 
the Edo series also fails to reveal statistical significance be- 
tween both sexes [x^ = 2.04 < p (0.01)]. 

SEVERITY OF INFECTIOUS CHANGE. Most infcCtioUS ICSionS 

of bone can be generally classified as either periostitis or 
osteomyelitis. As is well known, periostitis shows various 
degrees of involvement, from slight and weak change to 
severe and drastic (Stothers and Metress 1975; Lallo et al. 
1978). In this study the severity of such infectious change 
was basically classified into periostitis and osteomyelitis, 
and f)eriostitis was subdivided into two categories, slight and 
severe. Slight periostitis was defined as the extent of involve- 
ment of the periosteal surface (Lallo etal. 1978) correspond- 
ing to the stage 1-11 proposed by Stothers and Metress 
(1975). Severe periostitis was defined by the nature of tissue 
destruction — whether pitted, ridged, scarred, or showing 
sinus tracts (Lallo etal. 1978). The result is shown in Table 4. 
It should be noted that there is no clear evidence of os- 
teomyelitis in the Jomon series. 

Zagreb Paleopathology Symp. 1988 



II 



Table 2. F requency of infectious lesion types 

Period Category of No. (%) Total/no. (%) 

(no.) infection individuals 



Paleopathological study on infectious diseases in Japan • 133 
Table 3. Sex differences of lesions' frequencies 



Period Category of 
lesion 



Male Female Total 









Jomon 


Nonspecific 


15 


11 


26 


Jomon 

(272) 


Nonspecific 


26 (9.6%) 




Specific tbc. 
syph. 


- 


- 


- 




Specific tbc. 





Ainu 


Nonspecific 


6 


8 


14 




" syph. 







Specific tbc. 


1 


1 


2 










syph. 


1 


1 


2 






26/272 (9.6%) 


















Meiji 


Nonspecific 


6 


3 


9 


Ainu 


Nonspecific 


14 (7.9%) 




Specific tbc. 


2 


- 


2 


(178) 


Specific tbc. 


2 (1.1%) 




syph. 


2 


- 


2 
















syph. 


2 (1.1%) 




Total infections 


, 33/351 


24/212 


57/563 










Total (%) 


(9.4%) 


(11.3%) 


X ^ = 0.267 






18/178 (10.1%) 










p<.01 








Edo 


Syphilitic lesion 


39/636 


11/287 


50/923 


Meiji 


Nonspecific 


9 (8.0%) 




in skull (%) 


(6.1%) 


(3.8%) 


X' = 2.04 


(113) 


Specific tbc. 


2 (1.8%) 










p<.01 
















" syph. 


2 (1.8%) 













13/113 (11.6%) 
subtotal 57/563 (10.1%) 



Table 5. Secular changes of the 
frequency of lesions in the femur 
and tibia 



Edo 



Infectious lesion 






SkuU 


89 


89/923 (9.6%) 


Femur 


21 


21/308 (6.8%) 


Tibia 


31 


31/253 (12.3%) 


Syphilis in skull 


50 


50/923 (5.4%) 



Table 4. Severity of the infectious lesion 

Period Periostitis Osteomyelitis Total 
slight severe no. (%) 



Jomon 


21 


5 





26 


Ainu 


8 


2 


4 (28.6%) 


14 


Meiji 


5 


2 


2 (22.2%) 


9 



Period 


No./femur 
(%) 


No./tibia 

(%) 


Jomon 


17/332 
(5.12%) 


41/324 
(12.65%) 


Edo 


21/308 
(6.81%) 


31/253 
(12.25%) 


Ainu 


6/200 
(3.00%) 


3/194 
(1.55%) 


Meiji 


6/226 
(2.65%) 


12/226 
(5.31%) 


Total 


50/1066 
(4.69%) 


87/997 
(8.73%) 



SECULAR CHANGES OF THE FREQUENCY IN THE FEMUR AND 

TIBIA. The frequencies of infectious changes appearing in 
the lower extremities were compared. The reasons why the 
femur and tibia were selected in this examination are the 
following: (a) these bones, especially the tibia, are by far the 
most frequently affected by such infectious change (Golds- 
tein 1957; Brothwell 1961 ), (b) their broad periosteal surface 

Zagreb Palfopaihology Symp. 1988 



enables us examine them by gross observation with ease, and 
(c) a great number of isolated and unidentified femurs, tibias, 
and skulls in the Edo series at least can be used in the com- 
parison of frequencies. The result is shown in Table 5. The 
frequencies which represent the infected bones, including 
both nonspecific and specific changes, are calculated from 
the total number of femurs and tibias from both sides. 



134 • Takao Suzuki 





4 

m 


"''^^^^^^^ ^^^^^^^^^^H 




Figure 6. Three cases of advanced chronic osteomyelitis from Medieval period: left, right tibia of mature female from 
Ichino-Torii site (courtesy of Dr. A. Naito); center, distal end of right femur of adult from Zaimokuza site; right, left 
tibia of young individual from Katsuyama-Tate site. 



EVIDENCE OF SPECIFIC INFLAMMATION OF BONE. There waS 

no possible case of tuberculosis or syphilis in the Jomon 
skeletal series. Except for the Jomon series, typical cases of 
both tuberculosis and syphilis could be detected in the Edo, 
Ainu, and Meiji skeletal materials, as shown in Table 2. The 
frequency of these specific inflammatory diseases varies 
from 1 . 1 to 5.4% among the later three skeletal series. 

Discussion 

Based on a paleopathological study of the inflammatory le- 
sions in the skeletal materials of the Japanese from the Jomon 
(prehistoric) to Meiji (early modem) periods and the Ainu 
population, the qualitative transition of the infectious disease 
will be discussed here from the standpoint of their bio- 
ecological background. 

Taxonomically two major categories can be recognized: 
nonspecific inflammatory change including ordinary perios- 
titis and osteomyelitis, and specific inflammatory change 
caused by tuberculosis and syphilis, which can be defined by 
the typical/demonstrative morphology and distribution of the 
lesion. In a field of paleopathology dealing with dry-bone 
specimens, it is sometimes inevitable to encounter the bor- 
derline case showing equivocal inflammatory lesion between 
nonspecific and specific. This means that periostitis appear- 
ing in the dry bones may be treated as an independent entity. 
In this study, cases showing such equivocal periosteal reac- 
tion ("periostitis ossificans") were included as nonspecific 



inflammation. In this sense, specific bone diseases diag- 
nosed as tuberculosis or syphilis were detected with certainty 
only by the characteristic changes and distribution of bone 
lesions. 

QUALITATIVE TRANSITION OF THE INFECTIOUS DISEASES 

It should be emphasized that a relatively higher frequency of 
nonspecific inflammatory lesions represented by plaquelike 
periostitis appeared in the Jomon skeletal series. Further- 
more, almost all of them showed slight/moderate periostitis 
limited to the exterior surface of the bone, and there was no 
case showing severe/advanced chronic osteomyelitis with 
such characteristic features as involucrum. sequestrum, and 
cloaca formation. It should be noted that no such advanced 
case of osteomyelitis has been found to date anywhere among 
the Jomon skeletal remains, whose number is the largest in 
this country. One of the oldest cases of .severe advanced 
nonspecific osteomyelitis is from the medieval period (Fig- 
ure 6). It seems that such advanced infectious cases may be 
found more frequently among the population after the Jomon 
period provided that the number of skeletal remains from 
Yayoi and Kofun period are complete and sufficient to exam- 
ine paleopathologically. 

Why is the frequency of advanced infectious cases con- 
siderably lower in the Jomon series? The Jomon society de- 
pended on hunting, gathering, and fishing activities. The 
Jomon population density was estimated to be quite low. 

Zafireh Paleopathology Symp. 1988 



I 



Paleopathological study on infectious diseases in Japan • 135 



Table 6. Population number from earliest Jomon (prehistoric) to Kofun 
(protohistoric) period (Koyama 1984) 



Period 



Jomon Yawi Kofun 

earliest early middle late latest 



Population 20100 105500 261300 160300 75800 594900 5399800 
number 
Density/km^ 0.07 0.36 0.89 0.55 0.26 2.02 18.37 



Table 7. Reported palaeopathological cases of bone tuberculosis 



Designation 



Period Sex Age 



Location 



Reporter 



Shiroyama-No. 3 Kofun 

Unoki-No. 3 Kofun 

Asahidai - No. 9 Kofun 

Ainu - A - 1336 Ainu 



M Adult Spine (lumbar-sacrum) Ogata 1972 

F Mature -senile Spine (thoracic-lumbar) Suzuki 1978 

M Mature - senile Spine (thoracic-lumbar) Tashiro 1982 

Ribs 

F Adult Sacrum Suzuki 1985a 



Koyama's (1984:10-39) estimation of the population from 
the earliest Jomon to the protohistoric period is shown in 
Table 6. The average population density calculated in the 
Jomon period (0.43/km-) is about one-fifth of the Yayoi 
period (2.02) and one-fortieth of the Kofun period (18.37). 
Furthermore, Kobayashi (1967) stated that the average age at 
the time of death for the individual over 1 5 years of age was 
3 1 . 1 for males and 3 1 .3 for females. It is quite probable that 
the Jomon people had rather short lives, probably caused by 
some environmental factors such as unstable food supply, 
hard labor in hunting-gathering-fishing activities, and un- 
sanitary living conditions. These environmental factors also 
may have influenced the inflammatory process in the bone. 
The following tendencies can be suspected among the Jomon 
people; infection may extend rather easily to the bone, and 
individuals involved in such an infectious process tend to die 
before periostitis becomes chronic and develops into more 
advanced osteomyelitis. 

On the other hand, during the historic periods, probably 
due to the development of agriculture and gradual improve- 
ment of hygienic conditions, individual resistance against 
infectious diseases may change to produce more severely 
infected conditions of the bone as well as lengthen the aver- 
age span of life at the social level. However, at the same time 
it should be noted that other new epidemic diseases had been 
introduced and prevailed widely in this country at that time, 
accompanied by an increase in population density and 
domiciliation. These epidemic diseases consisted of the two 
specific infections, tuberculosis and syphilis. 

Zagreb Paleopathology Symp, 19H8 



ORIGIN AND PREVALENCE OF SPECIFIC 
DISEASES IN JAPAN 

It is remarkable that there have been neither typical nor sus- 
pected cases showing specific inflammatory bone changes 
among a huge number of Jomon skeletal remains excavated 
from various archeological sites in the Japanese archipelago. 
In the present study also, except for the Jomon skeletal series, 
typical/demonstrable cases of tuberculosis and syphilis were 
limited to the Edo and Meiji Japanese skeletons as well as the 
Ainu skeletal series. 

Four typical cases of spinal tuberculosis have been re- 
ported to date in Japan (Ogata 1972; Suzuki 1978; Tashiro 
1982; Suzuki 1985a) as shown in Table 7. None of them 
belonged to the prehistoric ( Jomon) population from which a 
great deal of well-preserved skeletons have been studied. 
The three oldest cases (Figure 7) belong to the protohistoric 
(Kofun) population in which there are considerably fewer 
skeletons than in the Jomon population. There seem to be two 
alternative possibilities why no case of bone tuberculosis has 
been found among so many Jomon skeletal remains. The first 
hypothesis attributes it to the lower population density of the 
Jomon period. Tuberculosis is a density-dependent disease 
and may have become established in human populations as 
the result of the appearance of such population aggregates 
(Cook 1984). In this sense tuberculosis might have existed in 
a very limited area as a local endemic form. Tuberculosis 
reached epidemic proportions after the Yayoi or Kofun period 



136 • Takao Suzuki 





Figure 7. Two cases of tuberculosis in the Kofun period: left, spine of adult male 
from Shiroyama-Kofun site (courtesy of Dr. T. Ogata); n^/i/, spine of mature 
female from Unoki-Kofun site. 



following a rapid increase of population density. Neverthe- 
less, it is still strange that not a single case of bone tuber- 
culosis has been found from the Jomon skeletal remains. As 
Morse ( 1961 ) pointed out, if prehistoric tuberculosis did ex- 
ist there should be many cases of typical spinal tuberculosis 
found among the large amount of excavated skeletal mate- 
rial. The second hypothesis is more probable, dealing with 
the migration of the causative organism Mycobacterium tu- 
berculosis. A great number of immigrants from the Asian 
continent migrated to this island country via the Korean Pen- 
insula during the Kofun period (protohistoric, ca. third to 
seventh century a.d.). Not only did they introduce various 
cultural characteristics including the Chinese writing system, 
agricultural methods, and crafts, but they brought some new 
infectious diseases, probably including smallpox and tuber- 
culosis, which disseminated throughout the country accom- 
panying a rapid increase of population. The oldest written 
record of respiratory tuberculosis appeared in a Buddhist 
medical book published in the 12th century in Japan. Many 
medical documents, particularly in the Edo period, described 
a high prevalence of lethal, respiratory tuberculosis among 
the p)eople. 

Unlike tuberculosis, the origin, dissemination and preva- 
lence of venereal syphilis have already been elucidated by the 
old medical documents. According to medical historians 



(e.g., Fujikawa 1904:172-177, 1912:42; Dohi 1921:70-75), 
the first outbreak of a virulent venereal infection appeared in 
this country in the decade following 1510, the late 
Muromachi period, and suddenly prevailed in epidemic pro- 
portions. The oldest documents describing the appearance of 
syphilis in Japan are two documents written in a.d. 1512 and 
1513. They showed that the first large outbreak of syphilis 
was in the western part of Japan and then spread to the north- 
eastern part within a year or so. The people at that time called 
this curious epidemic disease Tau-mo (Chinese eruption) or 
Ryukyu-mo (Ryukan eruption), which represent the original 
epidemic area before they were involved. This virulent epi- 
demic of syphilis struck the unsuspecting Japanese without 
distinction as to age and sex. During the Edo period, the 
people were very familiar with syphilis and called it by vari- 
ous names. Many documents deal with the clinical man- 
ifestations and therapies for syphilis during the mid and latter 
Edo period. 

Koganei ( 1 894) described a case of an Ainu archeological 
skeleton showing typical changes of osseous cranial syphilis 
(Figure 8), and Suzuki ( 1 963: 1 3- 1 5) reported the oldest case 
of osseous cranial syphilis from the Muromachi period (Fig- 
ure 9), stating that 3 out of 23 skulls ( 13.0%) had the typical 
features of os.seous syphilis. Another old case showing syph- 
ilitic change in the skeleton from a ruin of a medieval castle in 

Zagreb Pateopathology Symp. 1988 



. 



Paleopathological study on infectious diseases in Japan • 137 




Figure 8. Typical demonstrable case of cra- 
nial syphilis from an Ainu skeletal remains 
(originally reported by Y. Koganei in 1894). 




Figure 9. Typical demonstrable case of cra- 
nial syphilis from the Muromachi (medieval) 
skeletal remains (originally reported by H. 
Suzuki in 1963). 




Figure 10. Two typical demonstrable cases of cranial syphilis from the Edo (latest medieval/earliest modem) skeletal 
remains (originally reported by the author in 1984.) 



Hokkaido has been reported by the author (Suzuki 1984c). 
Furthermore, on the subject of the epidemic of syphilis dur- 
ing the Edo period, 50 of 923 (5.4%) Edo skulls could be 
diagnosed as demonstrable cases of osseous syphilis (Figure 
10) and in the biocultural background of the Edo people and 
its society these were interpreted as proving a high preva- 
lence of syphilis (Suzuki 1984a). 

Another major specific disease that affects the skeletal 
system, particularly the facial and foot bones (M^llcr- 
Christensen 1964), is leprosy. Recently some archeological 

Zagreb Paleopathology Symp. 1988 



cases from the medieval and early modem periods have been 
thought to be possible cases of leprosy in this country, though 
to date they have not been published. There are also no cases 
of leprosy found in the Jomon skeletal series. 

Nonvenereal fomis of trcponematosis such as yaws (fram- 
besia) and pinta must be dilTerentiatcd from venereal osseous 
syphilis if these two diseases coexist in the same area. In 
Japan, however, there has been no evidence of the existence 
of such tropical, endemic, nonvenereal infections either in 
the past or at the present time. 



138 • Takao Suzuki 



Conclusions 

A paleopathological study emphasizing infectious bone dis- 
eases was conducted on the skeletal mateinals from Jomon 
(prehistoric) to Meiji (early modem) Japanese and the Ainu 
f)eople. The frequencies, sex differences, and severity of the 
inflammatory lesions in the bones are presented as well as 
some interesting cases from various archeological sites. A 
taxonomical problem in the description of inflammatory 
changes is also discussed. 

Among a large numberof the Jomon skeletal remains there 
was no evidence of specific infectious diseases. The inflam- 
matory changes represented by slight/moderate plaquelike 
periostitis in the Jomon series seemed to be caused only by 
nonspecific infections. On the other hand, the other skeletal 
series included not only typical/demonstrable bone tuber- 
culosis and syphilis but also chronic/advanced osteomyelitis 
besides ordinary plaquelike periostitis, which document the 
coexistence of both nonspecific and specific infections in the 
Edo, Meiji, and Ainu populations. This difference found 
between the Jomon and the other series was consistent with 
biocultural differences such as the introduction of agricul- 
ture, settlement, increase ofpopulation density and urbaniza- 
tion in this country. 

The qualitative changes of bone infection by the two spe- 
cific infectious diseases of tuberculosis and syphilis were 
also considered from the standpoint of their origin (transi- 
tion), dissemination and prevalence in this country. 



Acknowledgments 

The author is deeply indebted to Professor Akio Yamauchi of 
the Department of Anatomy (III), Faculty of Medicine, The 
University of Tokyo, Professor Kazuro Hanihara and Associ- 
ate Professor Banri Endo of the Department of Anthropol- 
ogy, Faculty of Science, The University of Tokyo, and Pro- 
fessor Jiro Ikeda of the Department of Anthropology, Kyoto 
University, for their kind permission to examine the valuable 
materials in their universities. 

The author is also very grateful to Professor Yoshiatsu 
Naito of the Department of Anatomy (II), Faculty of Medi- 
cine, Nagasaki University, and Professor Takahiko Ogata of 
the Department of Oral Anatomy (II), Kagoshima University 
Dental School, for allowing him to use their valuable illustra- 
tions of infectious diseases in the bones. 

The author also wishes to express his gratitude to Donald J. 
Ortner, Curator of the Department of Anthropology, Smith- 
sonian Institution, for his kindness in reading the manuscript 
and offering many helpful suggestions. 



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1984b. Paleopathological Study on Osseous Syphilis in 

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Summary of audience discussion: Historical records suggest ve- 
nereal syphilis was introduced into Japan from China in 1512, a 
record consistent with the absence of treponemal lesions in the 
series reported here from Japan's Jomon period. Tuberculosis is not 
identifiable in these series until after the Jomon period either. The 
Jomon people had no or few domestic animals. 



Zagreb Paleopathology Symp. t988 



Epidemiological aspects of paleopathology in 
Denmark: Past, present, and future studies 

Pia Bennike 



r aleopathological studies have been carried out in Denmaric 
throughout the last hundred years, and with a few exceptions, 
the developmental stages do not seem to differ much from the 
general history of paleopathology known in other countries. 
The three stages are: the descriptive stage, the epidemiologi- 
cal stage , and the analytical stage . The number and subject of 
the studies within each stage may vary considerably, depen- 
dent on the time and the traditions of the geographical area. 

Some of the early Danish studies of epidemiological 
character have obtained international interest. This is due to 
several factors, one of them being the long archeological 
tradition in Denmark resulting in a well-documented skeletal 
collection with reliable datings. In large parts of Denmark the 
soil contents provide extremely good conditions for the pres- 
ervation of bones, and many Danish skeletons and bog 
bodies have been known to a wide audience, owing to the 
many details which could be studied. The size and the rela- 
tive homogeneity of the Danish population is also very suita- 
ble for studies of epidemiological aspects. Finally, an impor- 
tant factor is the role of the investigator, which must not be 
forgotten. 

In the following pages, we give a short presentation of the 
more important Danish studies dealing with paleopathology 
from past and present. Together they show the development, 
but also the restrictions, of this topic in Denmark over the 
years. We then discuss the results of the different studies in 
relation to the planning of future projects. 

Past 

As paleopathological studies in Denmark are mainly depen- 
dent on remains of human bones, the history can naturally not 
be traced farther back than to the establishment of the skeletal 
collection. 

In an 1837 publication the Danish scientist Eschricht re- 
quested that more skeletal material be preserved during ex- 
cavations. At that time the number of prehistoric skulls could 
be counted on the fingers of one hand. Eschricht's interest in 
acquiring more skeletal material was based on his wish to test 
certain theories concerning the Danish prehistoric popula- 
140 



tion. Several scientists had proposed that the ancestors of the 
Scandinavian people may have been either Eskimos or per- 
haps Lapps, and this hypothesis could only be tested by 
studying a larger number of skulls (Nilsson 1838; Eschricht 
1 84 1 ). The theories were based on a study of very few skulls 
with some eskimoid traits, but later studies showed that those 
traits were not common in most skulls and may be considered 
as an isolated variation. It also demonstrates that the smaller 
the volume of material studied, the easier it is to draw con- 
clusions. This is the case in studies of both physical an- 
thropology and paleopathology. Whether the subsequent in- 
crease in the number of recovered prehistoric skulls was due 
to Eschricht's request or was a natural result of the devel- 
oping scientific interest in anthropology at the time is not 
known. 

By the time the German professor Virchow in 1870 visited 
Copenhagen to study the Danish Neolithic population, more 
than 50 skulls were available (Virchow 1870). As most scien- 
tists of that time, Virchow focused on questions of normal 
variation and racial types and not on pathological conditions, 
but from that time on skeletal material was available for 
paleopathological studies. The studies of the period on paleo- 
pathological aspects were, however, few and the topics were 
mostly restricted to mere descriptions, often of lesions, in- 
fections or trepanations on single finds (Engelhardt 1877; 
Hansen 1889,1913; Kjaer 1912; Nielsen 1911). 

At an international conference in France in 1867 Broca 
demonstrated that traces on a Peruvian skull, previously in- 
terpreted as a lesion caused by a wound, were probably due to 
treatment, the so-called trepanation (Broca 1867). It is not 
difficult to imagine how exciting it must have been to the 
participants of that conference to look for similar cases in 
their "own" collections after their return. Several studies on 
trepanation were published in the years shortly after Broca's 
presentation , showing that at least some of his colleagues had 
success in "discovering" skulls with evidence of trepanation 
(Hansen 1889,1913; Nielsen 1911). 

Toward the end of the last century, a tradition of sending 
skeletal material from excavations to the Institute of Anat- 
omy in Copenhagen was established. Usually the old bones 

Zagreb Paleopathology Symp 1988 



Epidemiological aspects of paleopathology in Denmark • 141 



were not paid much attention there, but professor of anatomy 
Dr. Fr. C.C. Hansen was one of the few who became inter- 
ested in physical anthropology. He was a coauthor of Cra/i(« 
Groenkmdica (Furst and Hansen 1915) but is probably best 
known in the paleopathological world for his work on the 
remains of 25 skeletons of Norsemen excavated at Herjolfnes 
in Greenland (Hansen 1924). 

From written sources we know that the Norsemen settled 
in Greenland in the middle of the 10th century, but we also 
know that they perished for some reason, probably during the 
15th century. Theories on their disappearance have been pro- 
posed, such as: the Norsemen were killed by the Eskimos, 
the Norsemen may have become assimilated with the 
Eskimos, the Norsemen may have sailed away, or the Norse- 
men died from starvation. In spite of several studies, it is 
interesting that nobody has ever been able to confirm any of 
the theories and no satisfactory explanation has ever been 
advanced of how the medieval Norse settlers in Greenland 
perished. On the contrary, several findings from studies of 
the Norsemen's environment have shown that none of the 
theories above can stand alone. 

After studying the skeletons from a churchyard at Her- 
jolfnes in the older East settlement of Greenland, Hansen, 
however, drew the provoking conclusion that the Norsemen 
became extinct owing to inbreeding. His conclusion was 
based on the appearance of minor skeletal changes such 
as osteophytes, caries, paradontosis, and similar changes 
"commonly" seen in paleopathological studies. A pelvic 
bone according to Hansen was marked with rachitic changes 
but Fischer-M0ller ( 1942) later demonstrated that it was so 
badly damaged and deformed by postmortem changes in the 
grave that no clear conclusions could be drawn on the basis of 
this material. From an anthropometric point of view, Hansen 
furthermore based his conclusion on the small stature and 
also the relatively small volume of the skulls. 

All the single cases on which Hansen based his theory 
were later reexamined by Fischer-M0ller, who also studied 
newly excavated skeletons of Norsemen from Greenland. 
Fischer-Mrtllerwas able to reject almost ail the cases. Contr- 
ary to Hansen he did not find any evidence of abnormal 
degeneration as a result of inbreeding. It would be too exten- 
sive to go into the details of Fischer-M0ller"s rejection of the 
single cases here. A repetition of Hansen's concluding re- 
marks would probably be useful in showing today's pal- 
eopathologists how dangerous it can be to draw conclusions 
from paleopathological studies without having long experi- 
ence in studying skeletal changes and without having any 
comparative studies to lean on, in order to learn which 
changes are common and which are not. Hansen wrote: 

The vigorous northern race that originally colonized Green- 
land degenerated in the course of the centuries under the in- 
fluence of the hard and at last constantly deteriorating life 
conditions and other unfavorable conditions, especially iso- 
lation both intellectually, materially and as regards race 

Zaf^rrh Paleopathology Symp. I9HH 



hygiene. It became a race of small people, frail, physically 
weakened, with many defects and pathologic conditions. 

That a race so small in number, so weakened both by in- 
ternal and extemal unfavorable life conditions has neverthe- 
less been able to stay so gallantly at its post so long, much 
longer than was before conceived possible, speaks highly 
of the original quality of the race. 

In the fight the Norse must no doubt have been superior 
to the Eskimos, but the descendants of the people who 
sailed "westward on the sea" in small open boats and set- 
tled on the inclement shores of Greenland, defying nature 
through centuries, often at war with one another, did not 
succumb in struggle with men alone. Against constantly 
more severe physical conditions, against cold and a slow 
periodical starvation and in greater and greater isolation the 
northem race could not at last defend itself. Influences of 
nature which slowly and insidiously through the short life- 
time of several generations undermined the vitality of the 
race itself could in the long run only be conquered by help 
from the main country and by an inflow of fresh blood to 
give vitality to the enfeebled race. . . . This did not hap- 
pen. ... Its doom was sealed by the ice of Greenland. 
(Hansen 1924:520-521) 

The basis of this conclusion may be due to the investiga- 
tor's poor knowledge of what is normally seen of so-called 
pathological changes in skeletal studies. If Hansen was right 
in his interpretation based on less severe degenerative traits 
such as osteoarthritis, the whole human race should have 
become extinct thousands or maybe millions of years ago. 
Almost all adult skeletons show evidence of osteoarthritic 
changes. 

When most paleopathologists first started the study of hu- 
man skeletons, they probably remember how often they be- 
came excited by bones with pathological changes, which 
later turned out to be quite common and almost within the 
frame of normality. It is probably evident to all that the study 
of paleopathology demands both long experience and an ex- 
tremely wide knowledge of the nonpathological variations. 
Most colleagues of anthropology are specially trained in this 
field and are familiar with the literature available. If we want 
to exclude mistaken conclusions such as those Han.sen drew, 
it is necessary to develop a strong and wide collaboration 
between the anthropologists who have long experience in 
skeletal studies and the specialists of the different medical 
topics. 

It must be admitted that most anthropologists working in 
the field of paleopathology arc clearly somewhat restricted 
in their studies because of their relatively small experience in 
modem anatomy and pathology. A collaboration with experts 
in some medical fields is therefore highly recommended. It 
is, however, not always a pathologist who is needed. Some- 
times a specialist in orthopedic surgery, a clinical radiologist, 
or a dentist may be the best person to involve in the different 
cases. 



142 • Pia Bennike 



If we look at the epidemiological aspect of the past, studies 
of this kind already began in Denmark with the previously 
mentioned work on Norsemen by Hansen ( 1924), but it was 
soon followed in 1936 by a study of 400 medieval skeletons 
excavated at 0m monastery (Isager 1936). Isager, who exam- 
ined the bones, had a medical background as a general practi- 
tioner and was naturally most interested in describing the 
unusual pathological finds. Without having contemporary 
material for comparison his study was mainly a description of 
the pathological appearance of single bones. He also counted 
the number of bones with different kinds of defects, for ex- 
ample bones with evidence of healed fracture. However he 
did not count the number of normal bones, so no frequencies 
of the pathological changes in this material are known. Epi- 
demiologically the study is therefore of limited value, but 
contrary to Hansen, Isager was aware of not going to ex- 
tremes in his interpretation of the results before he had com- 
parative material. 

In the following decades the works of M0ller-Christensen 
totally dominated the field of paleopathology in Denmark 
(1953, 1958. 1961, 1963, 1967, 1978). Moller-Christensen 
started his activity in 1935 by excavating more than 700 
medieval skeletons at /Ebelholt monastery on Zealand 
(M0ller-Christensen 1958). He mainly studied the many 
pathological changes, which resulted in an excellent and use- 
ful publication, which unfortunately to date has been pub- 
lished only in Danish. The book contains tables with frequen- 
cies of almost all kinds of pathological changes seen in the 
medieval skeletons, and the results can therefore be com- 
pared to all later results of paleopathological studies. This 
makes the book on the skeletons from yCbeiholt monastery 
much more useful than the one based on the skeletons from 
0m monastery. It is also interesting to see the difference in 
the number of diagnoses mentioned in the two studies by 
IsagerandM0ller-Christensen. The number of different diag- 
noses is quite small in the book by Isager, while M0ller- 
Christensen mentions more than three times as many. This 
may primarily be owing to the different years in which the 
studies were carried out and to new methods developed dur- 
ing the second half of this century, which allowed more 
precise diagnoses to be made and described. 

After M0ller-Christensen finished his study on diseases in 
the Middle Ages based on the many skeletons from /Ebelholt 
monastery, he carefully planned his next study. One of the 
/Ebelholt skeletons had shown some changes that might have 
been caused by leprosy. During his search for comparable 
bones affected with leprosy he realized that very little was 
known of skeletal changes due to this disease. He therefore 
decided to elucidate this topic. From historical records it was 
known that the so-called St. George houses were scattered 
throughout Denmark during the Middle Ages. People af- 
fected with leprosy were forced to live there for the rest of 
their lives, separated from their friends and families. M0ller- 
Christensen succeeded in locating the place where one of 
these houses and the surrounding graves were situated. 



After acquiring permission to start excavating the graves in 
1941 , more than 200 skeletons were recovered. This material 
made it possible for the first time to study changes in bone 
due to leprosy on the basis of several hundred skeletons 
affected with the disease. This was indeed a collection of 
high value for paleopathological studies (M0ller-Christensen 
1961,1967,1978). M0ller-Christensen's exceptional study 
made it possible to add new points to the clinical diagnosis of 
leprosy. The typical changes of the maxilla and of the nasal 
aperture with the loss of the nasal spine had not been de- 
scribed in skeletons before. His studies may also in an inter- 
national sense be labeled as unique. Often our studies in 
paleopathology are restricted by a small sample size or mate- 
rial somehow selected to produce underrepresentation of cer- 
tain age or sex groups. In such cases its epidemiological 
value may be questioned. Sample size was not the problem in 
M0ller-Christensen's material from the leprosarium. The 
skeletons excavated at Nsestved are naturally not representa- 
tive for the average medieval population, but together they 
form an interesting group consisting of those who were ex- 
pelled from the normal community because of a specific 
disease. The study of this group was the aim of M0ller- 
Christensen's work. 

In recent years a new group of skeletons of several hundred 
individuals from almost the same area and period has been 
excavated. Future detailed studies will show whether the 
medieval people from Nasstved really managed to diagnose 
and expel all those affected with leprosy. M0ller-Christensen 
found that about 80% of the skeletons from the leprosarium 
showed some of the characteristic changes in bone due to 
leprosy, whereas this author, in a preliminary study of the 
skeletons from a common cemetery within the town, did not 
find any changes due to leprosy in the skeletons. 

Today, when Acquired Immunodeficiency Syndrome 
(AIDS) seems to threaten the modem world's population and 
the discussions of how to prevent and restrict contamination 
are varied and often heated, it is interesting to go back 600- 
700 years to see what happened in a somewhat similar situa- 
tion. At that time people who were suspected of having lep- 
rosy were doomed to spend the rest of their lives isolated in 
the St. George houses, and it is the remains of those people 
we are able to study today. Today leprosy is almost extinct in 
the West, but is still known in many developing countries. 

From modem studies we now know that leprosy is not 
highly infectious, and it is not necessary to force the affected 
people to live their whole lives isolated and expelled from the 
community; they can lead a normal life (Kom 1982). The best 
way to prevent the disease is to provide better living condi- 
tions. In a very poor area in Norway the disease disappeared 
only in the beginning of this century. The medieval people at 
the leprosarium seem to have suffered not only from the 
disease but also from condemnation by healthy people who 
wanted to protect themselves. Let us not repeat this mistake 
by isolating those affected with AIDS. In this case the bones 
of the dead may teach the living what should NOT be done. 

Zagreb Paleopathology Symp. 1988 



Epidemiological aspects of paleopathology in Denmark • 143 



Present 

Within the last decade several studies on different pal- 
eopathological aspects have been carried out, and several 
reports on dentition (Lunt 1978) and cervical changes of the 
back in relation to dental abscesses (Ingelmark 1956) have 
been based on the medieval skeletons from yCbelholt monas- 
tery. 

A very interesting study was also carried out by Andersen 
( 1 969) who compared the skeletal changes of the medieval 
skeletons from Nsstved with people affected with leprosy in 
living populations from India. 

Smaller studies of pathological changes found on mainly 
newly excavated skeletons have continuously been pub- 
lished. 

A recent study by the author was primarily based on 
Danish prehistoric skeletons and seems to constitute an addi- 
tional step in the development of pathological studies on 
epidemiological aspects (Bennike 1985). As an important 
f)oint, the study provided us a catalogue of information on the 
dating of all Danish prehistoric skeletons available for future 
studies of paleopathological aspects. This introductory part 
of the study was based on an archeological/anthropological 
collaboration which later resulted in several joint publica- 
tions of some of the special finds (Bennike and Ebbesen 
1986; Bennike et al. 1986). As a part of the work on the 
paleopathology of prehistoric skeletons all bones were regis- 
tered in a computer system containing changes of patholog- 
ical, traumatic, or degenerative character of the joints, the 
long bones, the irregular bones, and the skull. The many 
results have provided us with incidences of a number of 
pathological changes, comparative analysis of the results 
between different groups (age and sex) and between the pre- 
historic periods. This may be very useful in the planning of 
future studies in paleopathology of epidemiological and ana- 
lytic character. 

Future 

Shortly, we will begin a study of epidemiological aspects 
which may be considered a development and continuation of 
the previous paleopathology study of Danish skeletons men- 
tioned above. The title of the new study is: " A comparative 
analysis of methods to study nutritional and/or age depen- 
dent changes of the skeleton." The applied methods will 
include measurements of bone mineral content (BMC), 
osteon-analyscs (individual age determination), radiography 
(proximal femur spongiosa, Harris' lines), and finally the 
measurement and weight of a removed bone core (os- 
teoporosis). With regard to the dentition, the presence of 
enamel hypoplasia and paradontosis will be registered. The 
study may be divided into three steps: a test of the applied 
methods by the dissection of material of known age and sex, 
an analysis of possible correlation between the results of the 
different methods applied, and finally a discussion of the 

'/jignb Paleopathology Symp. 1988 



State of nutrition and the onset of aging in prehistoric man, 
based on the results of the study. 

With regard to the chemical analyses, especially the BMC, 
a control study of possible correlation between the content of 
calcium in the surrounding soil and in the bones will be 
performed. The skeletal material forming the basis of this 
analysis has been carefully selected. Most of the well- 
preserved skeletons were recently recovered in graves from 
the Viking period, and most skeletons were studied in situ by 
the author. 

Conclusions 

The Danish paleopathological studies of the past , present and 
future together form a developmental pattern of three stages: 
the descriptive, the epidemiological, and the analytical. In 
the years of the establishment of a Danish skeletal collection 
the pathological studies could naturally only be of a purely 
descriptive character. At that time nothing more could actu- 
ally be done owing to the small number of bones available, 
often from different locations. The lack of comparative stud- 
ies has also been a very important factor. In addition, most 
scholars had only a restricted experience in studying human 
bones and especially bones several thousand years old. 

Skeletal samples of a considerable size from the same 
excavation and site were later recovered allowing new kinds 
of paleopathological studies emphasizing epidemiological 
aspects. They were, however, still restricted to a presentation 
of tables of incidences of pathological skeletal and dental 
changes. The danger of making analytical studies and inter- 
preting the results at that time, without having comparative 
studies available, is clearly seen in the conclusion stated by 
Hansen as a result of his study of the Norse skeletons from 
Greenland. 

The almost contemporary work of Isager on medieval 
skeletons from 0m monastery has not been of much value to 
later studies either, but he did not draw any false conclusions. 
A new type of investigation started with the epoch of the 
many studies by M0ller-Christensen. His registration forms 
clearly show a new kind of development of the paleopatho- 
logical aspects. Systematically and in detail he registered 
both the normal and the pathological parts of the bones. 
There are several reasons why his work on the skeletons of 
medieval people affected with leprosy has been so highly 
acknowledged on the international stage: his systematic 
work, his comparison with studies of modem populations, 
and finally his well-planned projects. As one of very few 
scholars of paleopathology he also succeeded in transferring 
his results to clinical medicine. The facial changes of the 
skeletons affected with leprosy turned out to be useful in 
clinical diagnosis of the disease. 

Today almost 90% of all excavations take place without 
extensive planning because of the construction of new roads 
or buildings. The skeletal material is recovered by chance, 
and it is almost impossible to determine which skeletal 



144 • Pia Bennike 



samples should be studied next. In the days of M0ller- 
Christenscn he was able to plan his future studies even before 
the skeletons had been located. Real epidemiological studies 
allowing comparative analyses of results between different 
groups and periods first appeared in Denmark with some of 
the works of Moiler-Christensen on medieval skeletal mate- 
rial. Recently the paleopathological study of prehistoric skel- 
etons by the author has followed this tradition. 

The development of paleopathological studies ought not, 
however, to stop here, but the current database should rather 
be considered a necessary platform for new investigations 
using modem methods developed for paleopathology. 

A future study of prehistoric Danish skeletons has been 
planned mainly by the author, but many scientific specialties 
are included, and will result in an extensive collaboration 
with other scholars in this interdisciplinary project. Scholars 
from many different areas will be involved, mainly within the 
medical faculty. Other future works will probably also be 
marked by much more developed teamwork between schol- 
ars of different specialties, allowing more detailed methods 
to be presented and evaluated critically. 

Studies based on interdisciplinary cooperation have al- 
ready been common in archeology for several years. An 
increasing number of scholars, mainly of natural sciences, 
are involved in solving the many problems of prehistoric 
man's culture. In teamwork of this kind archeologists are 
naturally placed in the center, being those who gather the 
threads and synthesize the whole. 

Similarly anthropologists usually have an education ex- 
tending over a rather broad spectrum which may place them 
naturally in the center of specialists from different areas of 
medical, dental, paleontological, and chemical disciplines in 
studies dealing with problems of prehistoric man's biology. 
Thus, the future of paleopathology may prove to be very 
promising. 



Literature cited 

Andersen, J.G. 1 969. Studies in the Medieval Diagnosis of Leprosy 
in Denmark, Copenhagen: Costers Bogtrykkeri. 

Bennike, P. 1985. Palaeopathotogy of Danish Skeletons. A Com- 
parative Study of Demography, Disease and Injury, Copenhagen: 
Akademisk Forlag. 

Bennike, P., and K. Ebbcsen. 1986. The Bog Find from Sigersdai. 
Journal of Danish Archaeology, 5:85- 1 15. 

Bennike, P., K. Ebbcsen, and L. Bender J0rgensen. 1986. Two 
Early Neolithic Bog Skeletons from Bolkilde. Antiquity, 60: 199- 
209. 

Broca, P. 1867. Cas Singulicr dc Trepanation Chez les Incas. Bul- 
letins el Memoires de la Societe d'Anthropologie, 2:403-408. 

Engelhardt, C. 1877. Skeltgrave paa Sjxlland og det 0stlige Dan- 
mark. Aarh0ger for Nordisk Oldkyndighed og Historie, 347- 
402. 

Eschricht, D.F. 1837. ()m Hovcdskallcme og Benradenc i vore 
gamic Gravh0je. Dansk Folkeblad. 3:109-1 16. 



1841. Det kongelige Videnskabernes Selskabs Afhand- 

linger, 8, del 55. 

Fischcr-M0ller, K. 1942. The Mediaeval Norse Settlements in 
Greenland. Anthropological Investigations. Meddelelser om 
Gronland, 89(2). Copenhagen: Reitzels Forlag. 

Fiirst, CM., and Fr. C.C. Hansen. 1915. Crania Groenlandica, A 
Description of Greenland Eskimo Crania. Copenhagen: A.F. 
Host and S0n. 

Hansen, Fr. C.C. 1924. Anthropologia Medico-Historica Groen- 
landix Antiquae I. Herjolfnes. Meddelelser om Gronland, 
67:293-547. 

Hansen, S. 1889. Om forhistorisk Trepanation. Aarb0ger for Nor- 
disk Oldkyndighed og Historie. 1 70- 1 85 . 

1913. Primitiv Trepanation. Medicinsk Historiske 

Smaaskrifter. 5. Copenhagen: Wilhelm Trydes Forlag. 

Ingelmark, B.E. 1956. De Funktioneltt Anatomiska Forhdllandena 
i Ryggraden med Sdrskild Hiinsyn til dess Smdleder. Gothen- 
burg, Sweden: Goteborg Univcrsitels Arsskrift. 

Isager, K. 1936. Skeletjundene ved0m Kloster, Copenhagen: Levin 
og Munksgaard. 

Kja;r, H. 1912. Et markeligt arkaeologisk-antropologisk fund fra 
Stenalderen. Aarbog for Nordisk Oldkondskabs Historie, 58-72. 

Kom, J. 1982. Rehabilitering af Leprapatienter. Ugeskrift for 
Lceger, 50 1 . 

Lunt, D.A. 1978. Molar Attrition in Medieval Danes. In P.M. 
Butler and K.A. Jowsey. eds.. Development, Function and Evo- 
lution of Teeth. London: Academic Press. 

M0ller-Christensen, V. 1953. Ten Lepers from Niest\'ed in Den- 
mark, A Study of Skeletons from a Medieval Danish Leper Hospi- 
tal, Copenhagen: Danish Science Press. 

1958. Bogen om ALbelholt Kloster. Copenhagen: Dansk 

Videnskabs Selskab. 

1961. Bone Changes in Leprosy. Copenhagen: Munks- 



gaard. 



1963. Skeltfundene fra St. J0rgens Kirke i Svendborg. 

Fynske Minder, 35-69. 
1967. Evidence of Leprosy in Earlier Peoples. In D.R. 



Brothwell and A.T Sandison, eds.. Diseases in Antiquity, 295- 
307. Springfield, 111.: Charles C Thomas. 
1978. Leprosy Changes in the Skull. Odense, Sweden: 



University Press. 

Nielsen, H.A. 1911. Yderligere Bidrag til Danmarks Stenalder- 
folks Anthropologi. Aarb0ger for Nordisk Oldkyndighed og His- 
torie. 81-205. 

Nils.son, S. 1838. Skandinaviska Nordens Ur-lnvdnare . 1st edition, 
2-16. 

Virchow, R. 1870. Die altnordischen Schiidel zu Kopcnhagen. Ar- 
chivfiir Anthropologie. 4:55-91. 

Summary of audience discussion: A Yugoslav (Serbian) physi- 
cian was actually the first to describe the destructive nasal lesions of 
leprosy, reported in 1 904 at a Berlin symposium and published in an 
obscure circular from that meeting. The theory altribuling the talc of 
the southern Greenland colony of Norsemen to assimilation with 
Eskimos is not supported by physical evidence of dental traits or 
mandibular torus frequencies, but it could be evaluated further by 
testing the blood group pattern in the skeletal remains and compar- 
ing them with appropriate English, Danish. Norwegian, and Es- 
kimo population samples. 

Zagreb Paleopalhology Symp. 1988 



Human skeletal pathology in pre-Columbian 
populations of northern Chile 

Juan R. Munizaga 



Pre-Columbian populations on the arid coast of northern 
Chile succeeded in surviving during thousands of years in a 
very inhospitable environment and under strong selection 
pressures. Since diseases are one of the forces through which 
such pressures act, we may be able to detect them by the 
analysis of injurious effects left in the human skeletal re- 
mains. 

However, two great difficulties arise when studying the 
bone pathology of former populations of the Chilean arid 
coast. On the one hand, we know that those populations were 
never numerous and that most of their cemeteries have been 
disturbed. For these reasons it may be difficult to obtain an 
adequate sample. On the other hand, the bone reaction to 
disease is limited in variability and the types of injurious 
effects we found may not be identifiable with respect to 
etiology. Therefore, the knowledge we have of diseases in 
such populations is likely to remain incomplete for some 
time. 

One way to overcome these difficulties consists in analyz- 
ing the human skeletal remains available using an ecological 
approach, in which we try to establish the reactive patterns of 
bone caused directly by environmental stimuli. For the popu- 
lation under study, the health level will be primarily defined 
on the basis of the potential bone deterioration caused by 
those kinds of stimuli and the age attained by the individuals 
surviving in that environment. From this point of view, we 
tried to assess the health level of populations that lived on the 
arid coast of Chile and from which we have only a small 
number of skeletal remains. 

The sample and its ecological background 

The specimens used in this study constitute a sample of hu- 
man skeletal remains from populations which lived in a frag- 
ile, ecological balance on the arid coast of northern Chile. 
They were collected by L. Nunez ( 1971 ) during his excava- 
tions at the mouth of the Loa River and neighboring coves. 
The sample is made up of at least 50 individuals represented 
by skulls and a lesser number of bones from the remaining 
part of the skeleton, all of which are in different degrees of 

/4igrrb Paieopatbohgy Symp. 1988 



conservation. Most of them belong to immediately pre- 
Spanish periods. A very small number come from periods of 
about 2000 years ago. 

From a morphological point of view, the population corre- 
sponds to a Mongoloid population living on such a coast 
during several thousands of years, which occasionally re- 
ceived small migrations or visits from individuals coming 
from inland regions from both the Andean range of moun- 
tains and the Amazonian jungle. 

Two components of the physical environment must be 
distinguished. On the one hand, a narrow, coastal band, 
bounded inland by a chain of steep but low hills and the vast 
Atacama Desert that isolated it, is characterized by its ex- 
treme aridity (less than 5 mm of rainfall per year) and lack of 
vegetation. Its climate is humid due to "evaporation from the 
sea blown inland by the prevailing coast winds which is 
turned into mist by condensation when passing over the cold 
Humboldt current. In winter, this mist is left on the coastline 
hills, thus keeping a high degree of humidity in the atmo- 
sphere" (Weiss 1951:151). Water for drinking comes from 
highly brackish springs or "aguadas," whose solid concentra- 
tion ranges between 8.3 and 16.0 g/1 versus drinking water 
where the maximum is 0.5 g/1 (Lagos 1980:40). On the other 
hand, an offshore sea current is full of fish, shellfish, and 
mammals which, considered as food resources, are enough 
to support a great number of individuals. 

During several thousands of years, these populations kept 
on improving their cultural adaptation in such a way that in 
the late period, from which come most of the human skeletal 
remains here analyzed, they had attained an efficient naviga- 
tional expertise. Moreover, they mastered swimming and 
diving. This, added to their fishing or hunting food collection 
and preservation techniques, enhanced the groups" survival. 

In spite of that, evidence in the archeological, ethnograph- 
ic, and historical data as well as chroniclers' and travelers' 
statements suggest that the ecological balance was unfavor- 
able for the pre-Columbian people who lived in small num- 
bers in that coastal area. During the time of the Spanish 
contact, various epidemic diseases affected their popula- 
tions, which in time disappeared. 

145 



146 • Juan R. Munizaga 



Methods 

Our purpose was to detect the greatest number of injurious 
effects allowed by the examination techniques applied. We 
oriented our examination along two main lines: ( 1 ) patholog- 
ic conditions described by other authors, considered as com- 
mon in the pre-Columbian populations in America (Hrdlicka 
1914; Stewart 1979:271; Weiss 1958); (2) possible effects 
that can be caused by pressures on a sp)ecific ecosystem. In 
our case, we think that the most aft'ected apparati and systems 
may be the following: 

Cardiorespiratory system. Pressures upon this system are 
exerted through the humid environment produced by the 
coastal morning mists and the dust raised by the wind, which 
affect the respiratory tract of children and adults (X. Vivan- 
co, pers. comm. ). Apnea and fast decompression during div- 
ing may cause serious health problems among fishermen of 
the coastal area up to the present (Bittmann 1986:54). 

Locomotor}' apparatus. The physical effort made in swim- 
ming, rowing, and diving, as well as in fishing, hunting, and 
food collection and transport, placed the locomotory appara- 
tus under almost perpetual stress. We will use the degenera- 
tive changes that may have occurred in the joint surfaces 
involved in these actions as indicators of its effect. 

Digestive system and water and salt balance. In this case, 
pressures were made by the consumption of food with abra- 
sive (sand) and toxic elements, such as mammal liver and 
fish rich in vitamin A (Bamicot and Datta 1956:525), in 
addition to the ingestion of brackish waters. The indicators of 
their action will be wear and the loss of teeth in addition to 
infectious disease and metabolic bone alterations. 

The presence of disease was determined through inspec- 
tion, palpation and x-rays (Harris" lines). 

The degree of degeneration of joint surfaces was diag- 
nosed by the presence of lipping, erosion, and ebumation. 
The first was scored according to the degree of development 
of osteophytes, and the last two, on the basis of the extent of 
the destruction produced in articular surfaces (Stewart 1969; 
Ortner 1968; Yamaguchi 1984). 

Age determination was based on fusion of epiphysial and 
cranial vault sutures. For this purpose skulls were classified 
in the following categories: Adult 0, vault sutures open, 
basioccipital synchondrosis closed; Adult 1, outer suture 
open, inner suture in the process of closing; Adult 2, outer 
and inner sutures closing; Adult 3, outer and inner sutures in 
advanced stage of closure. 

Results 

I classify three groups of stress according to their frequency 
and to the knowledge we have of their causes: Group 1, a set 
of signs corresponding to reaction patterns deriving from 
well known environmental stimuli common to the whole 



population; Group 11, signs whose causes are known but their 
frequency is low; Group 111, signs whose causes are unknown 
but that appear somewhat frequently in this population. 

GROUP I 

LOCOMOTOR APPARATUS AND PHYSICAL EFFORT. The effort 

made in swimming, rowing, diving and getting food in this 
environment forced the individuals of this population to 
stress their joints, which led first to a plastic response, which 
enabled them to increase their motion capacity through the 
creation of new joint facets or the extension of the normal 
ones. However, on occasion the stress was too strong, caus- 
ing the progressive destruction of joint surfaces. It should be 
noted that the highest degree of destruction is found in the 
newly formed joint facets (excepting the front tibial facet) 
and then the facets of the elbow and knee joints. This finding 
is in agreement with that of other authors such as Stewart 
(1969), Jurmain (1977,1980), and Yamaguchi (1984). My 
findings are shown in Table 1 . 

MASTICATION APPARATUS AND FOOD. As a rCSUlt of chCwing 

hard food containing abrasive elements, a clear, reactive 
pattern is observed which, through wear, caries and frac- 
tures, leads to a completely edentulous status. In most cases, 
compensating phenomena, such as secondary dentine forma- 
tion, do not compensate for the wear. Compensating mecha- 
nisms are also hampered by infection which, through the 
roots, causes periapical problems leading to the destruction 
of alveolar bone. In addition, owing to the loss of the back 
teeth, the front teeth are subject to greater use, so that the 
temporomandibular joint receives abnormal stress, some- 
times giving rise to the degeneration of the joint surface. My 
findings are shown in Table 1 . 

GROUP II 

Owing to the variety of features found in this group and to 
their low frequency, we give some details of each case. Fre- 
quencies are shown in Table 2. 

Harris' lines. The average number of growth arrest lines 
observed per tibia is 1 . 1 and the percentage of affected tibiae 
in the population is 40.0. These values are similar to those 
found for pre-Columbian populations in the northernmost 
Chilean coast (1.5 and 35.6% respectively), but they are 
different from those occurring in the inland farming popula- 
tions, which show a great frequency of these lines both at an 
individual and at a population level: 6.2 and 67.8% respec- 
tively (Allison et al. 1981:270). 

Hypoplastic lines of enamel. Though we established their 
presence in several individuals, we could not determine their 
frequency due to the high rate of postmortem loss of teeth 
found in this population sample. 



Zagreb Paleopathology Symp. 1988 



Human skeletal pathology in pre-Columbian populations of Chile • 147 



Table 1. Injurious effects and reactive 
patterns of mastication and locomotor 
apparatus 



Group I 

MA^nCATION APPARATUS Nt (%) 



Dental caries 






?(-) 


Dental fractures 






?( + ) 


Antemortem dental 




35 (54.2) 


absence 










Periapical abscess 




35 (40.0) 


Palatal abscess 






35 (11.4) 


Antral fistula 






35 (5.7) 


Tumors or 


cysts 






35 (2.8) 


LOCOMOTOR APPARATUS 


Nt (%) 


Third condyle 






25 (44.0) 


Radioulnar joint 




17 (88.2) 


(extension) 








Poirier's facet 






20 (65.0) 


Tibial facet 






17 (100.0) 






Nt 


(1) 


(2) 


Humerus 


P 


14 


0.0 


0.0 




D 


17 


23.5 


52.9 


Ulnae 


P 


18 


5.5 


11.1 




D 


18 


0.0 


0.0 


Radius 


P 


20 


0.0 


0.0 




D 


17 


0.0 


0.0 


Femur 


P 


20 


0.0 


0.0 




D 


16 


0.0 


25.0 


Tibia 


P 


17 


5.8 


11.7 




D 


17 


0.0 


0.0 


Fibula 


P 


15 


6.6 


6.6 




D 


18 


0.0 


0.0 



NOTE: Nt, total number cases; (%), 
frequency; ( - ), absence; ( + ), presence; 
(1), lipping (medium degree or 
greater); (2), incidence of erosion; P, 
proximal articular surfaces; D, distal 
articular surfaces. 



Table 2. Injuries and skeletal lesions 


Group II 


Nt (%) 


Dental hypoplastic 


?( + ) 


Harris' lines in 


15 (40.0) 


tibiae (av. 1.1) 




Fracture 




Single 


?( + ) 


Multiple 


?( + ) 


Disc hernia (') 


?( + ) 


Paraplegia (') 


20 (5.0) 


Alteration of 


?( + ) 


lumbar column 




Periostitis 


16 (31.2) 


Infection 


20 (5.0) 


Cholesteatoma 


40 (2.5) 


Group III 


Nt (%) 


Alteration longitudinal 


40 (100.0) 


superior smus 




Cribra Cranii 




Orbitalia 


45 (6.6) 


Parietalia (active stage) 


45 (2.2) 


Thickness of bones over 




top of cranial vaults 




8 mm and up 


26 (57.6) 


9 mm and up 


26 (46.1) 


Obelionic osteoma 


40 (13.3) 


Auditory osteoma 


40 (12.5) 



NOTE: Nt, total number of cases; (%), 
frequency; ( + ), presence; ('), belong 
to same skeleton. 



Single fracture. Consolidated fracture of the zygomatic 
arch of a male adult individual. The skull shows an intention- 
al deformation of a tabular type, indicating that it comes from 
an inland population. 

Multiple fractures and deformations. These were seen in a 
male adult showing consolidated fractures in the second and 
third ribs; deformation and diminution in size in the clavicle 
of the same side; radius alteration (fracture?) with signs of 
inflammation; alterations in the areas of the serratus magnus 
and latissimus dorsi muscle insertion in the anterior face of 
the lower angle of both scapulae. Cause: possible fall on his 
shoulders during heavy load transport. 



Zagreb Paleopathology Symp. 1988 



148 • Juan R. Munizaga 



Disc hernia? An oval defect 10 mm wide and 5 mm deep 
was found in the lower face of the 1 1 th dorsal vertebra body 
and which communicated with the vertebral canal. A similar 
but smaller injury was found in the upper face of the 12th 
dorsal vertebra body. No reactive bone formation is ob- 
served. 

Paraplegia. A symmetrical alteration in the shape of 
femoral diaphysis was present in a male adult in the form of a 
slight decrease of its diameter and several symmetrical de- 
pressions of oval shape and longitudinal direction. It might 
correspond to a bone involution produced by a paralysis of 
the vastus medialis muscle, since in this individual the defect 
occurred between the 11th and 12th dorsal vertebrae de- 
scribed above and, owing to its opening to the spinal canal, it 
might have involved the lumbar plexus, whose upper fibers 
innervate that muscle. 

Alterations of the lumbar column. A case of incomplete 
sacralization of the fifth lumbar vertebra and one of trans- 
verse apophysis separated from the third? lumbar were 
found. This diagnosis is based on the presence of slight joint 
facets. Both trauma and hereditary defect are diagnostic pos- 
sibilities (Stewart 1969:448). 

Periostitis. Signs such as longitudinal striations were ob- 
served in long bones and, in some cases, deposits of thin 
bone sheets on the outer table. 

Generalized infection. This was found in a female adult 
whose lower limb bones appear thickened with an irregular 
surface. 

Cholesteatoma. A globular widening of the auditory canal 
with a thinning of the tympanic plate (Stewart 1979:268). 

GROUP III 

Pathologic signs of this group are shown in Table 2. 
Injuries 

GROUP I 

The bone reactive patterns we have described are well known 
and their relationship to the environment we have described 
are apparent. When interpreting their elements, confusion 
may arise concerning the boundaries existing between the 
normal, plastic response and the pathological response. 

GROUP II 

Injuries described for this group may be analyzed under three 
.separate headings according to their most general causes. 

GROWTH ALTERATIONS. Evidence arising from Harris' lines 
and hypoplastic lines in the enamel of this population is 



rather contradictory and, based on such evidence, it would be 
impossible to provide a clear diagnosis of poor health condi- 
tions during childhood. 

ACCIDENTS. The presence of traumatic accidents caused by 
aggression are minimal in this population, since the only 
available trace of intentional blows appears in an individual 
whose origin must be sought in inland populations where the 
signs of violence appearing in the skulls range between 4 and 
18% (Munizaga 1974:38). The remaining injuries falling un- 
der this heading seem to correspond to accidents during work 
activities. Thus, the rib fractures, disc herniation and associ- 
ated paraplegia, and even the lumbar column malformations 
we have described may have these causes, as well as infec- 
tions whose origin seems to be located in the legs. The latter 
can be understood if we remember that the highest risk was 
run by individuals of this group while sailing in rafts made of 
inflated hides, their legs being the most exposed parts of their 
bodies. An author who observed these rafts in 1780 tells us 
that "sometimes it happens that dolphins, sharks or other 
large fish puncture them and fishermen are left in a dangerous 
situation" (Bittmann et al. 1980:70). 

ENVIRONMENTAL ACTION. We would have to analyze chol- 
esteatoma under a separate heading. Stewart (1979:268), 
who is perhaps the only one who has recorded it, describes a 
pattern of differential distribution for Eskimos and Aleuts on 
the one hand, among which he has recognized 15 cases, and 
the more southern natives on the other hand, where he only 
mentions one case coming from Peru. Based on the medical 
evidence available for diseases of the ear in the present popu- 
lations of Alaska, he poses the possibility that this pathologic 
condition might correspond to a cholesteatoma and that it 
may be related to the cold weather of the Arctic region. 

The finding of a case in tropical latitudes is, therefore, 
hard to explain. Nevertheless, we have found two other cases 
showing this pathological condition in pre-Columbian indi- 
viduals of coastal populations in the vicinity of the one we 
have described (Pisagua and Cobija). Then, considering the 
number of cases examined for this area, their frequency in 
Alaska and the arid coast of Chile is likely to be similar. In 
addition, if we remember that the fishermen we have de- 
scribed dive in the waters of the Humboldt current with its 
characteristic low temperatures, the causal agent may also be 
the same. 

GROUP III 

I am not certain about the causes of the injurious effects we 
have described in this group, but various hypotheses may be 
posed about their origin. I think that they may be explained 
by three patterns of bone reaction. 



Zagreb Paleopathology Symp. 1988 



Human skeletal pathology in pre-Columbian populations of Chile • 149 



ALTERATION OF THE ENDOCRANIAL RETURN CIRCULA- 
TION. The swimming stroke used in the coastal region cons- 
ists of maintaining only the head outside the water. In con- 
trast, hunting and food collecting on land tends to direct the 
eyes and head downward. These head positions induce a 
hyperextension and hypertlexion of the occipitoatloidal joint 
as shown by the frequency of the third condyle and the de- 
generative changes in the joint surfaces of ail of them. I think 
that these sustained and frequent movements must have hin- 
dered in a mechanical way the intracranial return circulation 
at the level of vessels and plexus surrounding the foramen 
magnum. It is also possible that, during the first years of life, 
an internal cause has been added: brain edema. This condi- 
tion might be caused by the increase of intracranial pressure 
due to fluid retention produced by the ingestion of brackish 
water. This would alter the return circulation, as shown by 
the alteration of the course of the superior longitudinal sinus 
(formation of an endobregmatic lagoon or cistern), which 
would be a more apparent sign (see Table 2). 

ALTERATION OF THE BLOOD CALCIUM LEVEL. Sudden de- 
compression during diving and perhaps the ingestion of food 
rich in calcium may have raised the level of this element in 
the blood. For mechanical reasons, calcium should tend to 
concentrate in the blood stasis zones of the brain and produce 
extravasation of the emissary vessels in the passing zones, 
specifically in the ectocranial surface surrounding them on 
their way out. This might explain the bone neoformation 
described for the obeliac region and even the osteoma of the 
auditory meatus. 

THICKNESS INCREASE OF CRANIAL BONES. A bone reaction 
pattern which led to a thickness increase in the bones was 
posed a long time ago for pre-Columbian populations in the 
arid coast of northern Chile, without an explanation for its 
causes (Vergara-Flores 1894, 1905; Fonck 1906). Findings in 
this population confirm its presence, but its frequency and 
intensity are lower than those established for a great number 
of populations in America (Munizaga 1984:40). 

Various causes have been given to explain this bone reac- 
tion pattern: diet, such as vitamin C (Bourne 1956) and D 
deficit, hypervitaminosis A (Fonck 1906); anemia (Angel 
1967; Munizaga 1965); and inheritance (Weidenreich 1943). 
In this case, while an exaggerated thickness in reinforcement 
zones is likely to be explained from a genetic point of view, 
the increased thickness of the vault bones may also be due to 
the first two already mentioned causes. It must be pointed out 
that we have not found the orbital and parietal sieve plates 
characterizing porotic hyperostosis. It might be that its ap- 
pearance was modified by the alterations of the endocranial 
return circulation appearing in this population in infancy. The 
sole case we have found of sieve plates in their active phase is 



Table 3. Sex and age distribution on basis 
of skulls 

Group I 
Ages Infants Males Females Total 



AO 




1 


15 


16 


Al 




5 


10 


15 


A2 




10 


1 


11 


A3 




2 





2 


A? 







1 


1 


TOTAL 


4 


18 


27 


49 



NOTE: AO, vault sutures open, basilar 
closed; Al, outer open, inner in closing 
process; A2, outer and inner in closing 
process; A3, outer and inner in advanced 
closing process. 



similar to the one described by Ortner and Putschar 
( 1 98 1 :275 , Figure 4 1 7 ) as an example of rickets. In this case, 
it would be difficult to accept the presence of such a patholog- 
ic condition. 

Health relations to ecological balance 

The results of the examination of bones belonging to these 
populations are surprising for two reasons: ( 1 ) low frequency 
of cases of massive infection, of disabled individuals or ones 
with advanced joint deterioration, as these frequently occur 
in pre-Columbian to agricultural populations; and (2) ab- 
sence of old individuals and high mortality of women in early 
adulthood (see Table 3). Perhaps these human skeletal re- 
mains were collected in a selective manner, as has been 
shown to occur in other collections (Stewart 1969:444), or 
selective loss of skeletal remains of one age group occurred, 
such as when these are left on the surface (as we confirmed in 
a neighboring field, where the loss of children's bones was 
four times higher than that of adults' bones; Munizaga 
1980:206). Llagostera (pers. comm.) has also obscr\'cd im- 
portant variations in age classes in pre-Columbian cemeteries 
of this zone. 

In spite of the possibilities analyzed, which might explain 
this demographic distribution, 1 am inclined to think that 
these populations are in balance and any normal or abnormal 
alteration hindering the integration of an individual may be 
the cause of his removal from the system. This would also 
occur with pregnancy and might explain the mortality of 



Zagreb Paleopathology Symp. I98S 



150 • Juan R. Munizaga 



young women observed. In other words, human skeletal re- 
mains of these populations in fragile balances are likely to 
appear rather free of pathology, since any disease may cause 
the death of individuals long before such disease has time 
enough to attack the bone system. 

Conclusions 

On the basis of the bones examined, this population shows a 
high health level, characterized by a low prevalence of 
chronic infections, absence of signs of violence, and a low 
rate of accidents. However, the following reactive patterns of 
bone may be distinguished: reinforcement and deterioration 
of joint surfaces, loss of teeth and periapical processes, al- 
terations of the endocranial return circulation, osteomas of 
the ear and the obeliac region, and increased thickness in 
bones. There is no doubt about the validity of the first two. 
The others are presented as hypotheses. 

However, the apparent high level of health observed in this 
population seems to be the result of the elimination of people 
who had difficulties in adjusting to the environment. This 
could happen even to people affected by minor and transitory 
disability, such as pregnancy. Perhaps those factors may ex- 
plain the limited size of these populations observed in the arid 
northern coast of Chile by travelers visiting them in the past. 



Literature cited 

Allison, M., G. Focassi, and E. Gerszten. 1981. Estudio Radi- 
ografico y Demografico de Morbilidad y Mortalidad de Pueblos 
Precolombinos de Peru y Chile. Chungara. 8:256-274. Arica, 
Chile: Departamento de Antropologia, Universidad del Norte. 

Angel, J.L. 1967. Porotic Hyperostosis or Osteoporosis Sym- 
metrica. In D. Brothwei! and A.T. Sandison, eds.. Diseases in 
Antiquity. .378-389. Springfield. III.: Charles C Thomas. 

Bamicot. N.A., and S.P. Datta. 1956. Vitamm A and Bone. In 
G.H. Boume, ed.. The Biochemistry and Physiology of Bone. 
507-538. New York: Academic Press. 

Blttmann. B . 1 986. Recursos Naturales Renovahles de la Costa del 
Norte de Chile. 1-66. Tokyo. 

Bittmann,B.,M.T. Ahumada.andN. Montenegro. 1980. ElSurgi- 
miento, Desarrollo, Decadencia y Abandono de Cobija-Lamar: 
Notas Historicas. In B. Bittmann, et a!., Cohija. Proyecto de 
Investigaciones Interdisciplinarias en la Costa Centro Sur And- 
ina (Chile). 63-120. Antofagasta, Chile: Universidad del Norte. 

Boume, G.H. 1956. Vitamin C and Bone. In G.H. Boume, ed.. 
The Biochemistry and Physiology of Bone, 251-286. New York: 
Academic Press. 

Fbnek, F. 1906. Los Crdneos dc Paredes Graesas segun Vergara 
Rores. Un Dato Mas. Revisia Chilena de Hisloria Natural. 10. 

Hrdlicka, A. 1914. Anthropological Field Work in Peru in 1913, 
with Notes on the Pathology of the Ancient Peruvians. Smilh.\o- 
nian Institution Miscellaneous Collections, 61 :54-61 . 



Jumiain, R.D. 1977. Stress and the Etiology of Osteoarthritis. 
American Journal of Physical Anthropology. 46:353-365. 

1980. The Pattem of the Involvement of Appendicular 

Degenerative Joint Disease. American Journal of Physical An- 
thropology 53:143-150. 

Lagos, R. 1980. Un Estudio Geoecol6gico de la Costa deCobija; El 
Factor Geomorfologicoy la Existenciade Agua. InB. Bittmann, 
et al. , Cobija. Proyecto de Investigaciones Interdisciplinarias en 
la Costa Centro Sur Andina (Chile). 3 1 -47. Antofagasta. Chile: 
Univcridad del Norte. 

Munizaga, J.R. 1965. Espongio Hiperostosis (Humpcrl y Weiss) u 
Osteoporosis Simetrica (Hrdlieka). Diagnostico. Epidemiologia 
Antigiiedad. Revista de Antropologia, 3(1 ):39 1-394. Univer- 
sidad de Chile. 

1974. Paleoatologia Chilena. Antropologia. scgunda ep- 

oca, 1:35-39. Santiago, Chile: Departamento dc Ciencias 
Antropologicas y Arqueologicas, Universidad dc Chile. 

1980. Restos Oseos Humanos de la Costa Norte de Chile. 



Analisis de Cementerios Disturbados de Cobija, II Region, 
Chile. In B. Bittmann, et al., Cobija: Proyecto de Investiga- 
ciones Interdisciplinarias en la Costa Centro Sur Andina (Chile). 
vol. 1, 199-216. Antofagasta, Chile: Universidad del Norte. 
1984. Craneos de Paredes Gmesas. Revista Chilena de 



Antropologia. 4:19-61. Santiago, Chile: Universidad de Chile. 

Nunez, L. 1971. Secuencia y Cambio en los Asentamientos Hu- 
manos de la Desembocadura del Rio Loa, en el Norte de Chile. 
Boletin de la Universidad de Chile. 3-25. Santiago, Chile. 

Ortner, D.J. 1968. Description and Classification of Degenerative 
Bone Changes in the Disal Joint Surfaces of the Humerus. Ameri- 
can Journal of Physical Anthropology. 28: 1 39- 1 56. 

Ortner, D.J., and W.G.J. Putschar. 1981. Identification of Patho- 
logical Conditions in Human Skeletal Remains. Smithsonian 
Contributions to Anthropology. 28. Washington, D.C.: Smithso- 
nian Institution Press. 

Stewart, T.D. 1969. The Effects of Pathology on Skeletal Popula- 
tions. American Journal of Physical Anthropology. 30:443-450. 

1979. Patterning of Skeletal Pathologies and Epidemiol- 
ogy. In W.S. Laughlin, ed.. First American: Origins. Affinities 
and Adaptations. 257-274. New York: Wenner-Gren Foundation 
for Anthropological Research. 

Vergara Flores, L. 1894. Craneos de Indios Bolivianos. Actes So- 
ciete Scientifique du Chili. 4:231-250. 

1905. Craneos de Paredes Gmesas. (Nuevas Investiga- 
ciones de 63 Craneos de Quillagua y Algunos de la Costa). Re- 
vista Chilena de Historia Natural. 9: 172- 190. 

Weidenreich, F. 1943. The Skull of Sinanthropus Pckinensis — A 
Comparative Study on a Primitive Hominid Skull. Paleontologia 
Sinica. new series D, 10. Pehpei, Chungking. 

Weiss, P. 195 1 . Geografia de las Enfermedades en el Peru en Rela- 
ci6n con las Zonas Climaticas. Conferencias de Ciencias 
Antropologicas. 140-167. Homenaje al IV Cenlenario de la Fun- 
dacion de la Universidad Mayor de San Marcos dc Lima. 

1958. Osteologia Cultural. Lima, Peru. 

Yamaguchi, B. 1984. Degenerative Changes in the Distal Humerus 
and Femur. Bulletin of the National Science Museum. 10:9-17. 
Tokyo. 



Zagreb Paleopathology Symp. 1 988 



Observations on health, genetics, and culture 

from analysis of skeletal remains from 

Roonka, South Australia 

Miroslav Prokopec and Graeme L. Pretty 



Site and environment 

The skeletal material reported here comes from the archeo- 
logical site Roonka Flat on the right bank of the Murray 
River, 8 km north of Blanchetown in South Australia. The 
flat has a semicircular shape, is open to the west and bordered 
by lagoons on the northern and eastern sides. Steep cliffs of 
Tertiary deposits face the flat on the opposite side of the river. 
The Aboriginal tribe which occupied the area at the time of its 
colonization by Europeans in 1844 was known by the name 
Ngaiawang. Freshwater mussels, fish, marsupial game and 
rodents and various plant foods are assumed to have formed a 
large proportion of the diet of the original inhabitants. A sand 
dune located on an elevated place on the Roonka Flat was 
frequently used as a burial site. It is likely that it was used 
also as a camp site because of its pleasant position. Heaps of 
mussel shells were found at several places. 

Human bones began to emerge from the soil in the early 
1960s following floods and strong winds. Systematic ex- 
cavations were commenced by one of us (G.L.P.) in 1968 
with the support of volunteer labor and continued until 1976. 
Most of the excavated graves (n = 1 1 1) come from trench A, 
which was laid on the top of the dune, others from trenches 
OA, lA, IB, B and from the bulks between the trenches. 
Several skeletons were brought to the museum prior to the 
beginning of systematic research. 

Materials and methods 

CHRONOLOGY OF INHUMATIONS 

Carbon from the basal zone of trench A was dated 18,000 
years b.p. (Phase Roonka I) and carbon associated with one 
of the older groups of skeletons was dated about 7000 years 
B.p. (Phase II). Intermediate group Ilia is dated approxi- 
mately 4000 years b.p. and the youngest group Illb is esti- 
mated to have terminated at circa a.d. 1850 (Pretty 1977). 
The site was thus used from time indefinite to the period of 

Zagreb Paleopalhotogy Symp. t988 



European contact. Questions posed to physical anthropolo- 
gists were: who were the people; what did they look like; 
which diseases affected them and which were the most proba- 
ble causes of death? 



LABORATORY 

The bones available for assessment in the laboratory were in 
a poor state. Most of the skulls had to be reconstructed and 
sealed together from many fragments. Most of the skeletons 
were incomplete. 

Analysis of human osteological remains from Roonka 
showed that the same type of people occupied the flat for at 
least 7000 years and made a positive contribution to archeol- 
ogy by throwing light upon demography, health status, cul- 
ture, way of life, and genetics of the past population. At- 
tempts were also made to evoke the appearance of some 
individuals by drawing or modeling the missing soft parts on 
the skull. 



DEMOGRAPHY 

Current methods described (Martin and Sailer 1957; Lamach 
and Freedman 1964; Hrdlicka 1947; Stewart 1952; Krogman 
1962;Brothwell 1963; Trotter and Gle.ser 1952) were used to 
determine sex, age and stature from the bones. Pathological 
changes in the bones were reviewed with C.L. Manock and 
D. Pounder (pathologists), and D. Simpson, a neurosurgeon, 
reviewed a special case of a complete craniosynostosis in a 
child. Demographic aspects were studied according to Ac- 
sadi and Nemeskeri (1970) and Stloukal and Hanakova 
(1971). 

Results 

There were 165 individuals identified in Roonka, including 
60 (36%) children and subadults, 58 males (35%) and 47 
females (29%). The mean age of all individuals buried at 

151 



152 • Miroslav Prokopec and Graeme L. Pretty 




Figure 1 . Healed fracture of femur with over- 
ride and slight angulation of humerus and ulna. 
All photographs, with the exception of Figure 2, 
by M. Prokopec. 



Roonka was about 24 years , of males over 20 years of age 36 
years, and of females 32 years. The mean stature of males 
was 1 67.4 cm (SD 6.1 cm), andof females was 156.5 cm (SD 
5.4 cm). The difference in the mean height between both 
sexes amounted to 10.9 cm. The greatest mortality was in 
early childhood and in the adult group between 20 and 30 
years of age. The least represented age groups in the sample 
were children of approximately 10 years and those of the 
senile group over 60 years of age. 

HEALTH STATUS 

Conclusions on general health of people once living at Roon- 
ka may be drawn from the age at which people died, from 
stature, from size and shape of bones, and from traces of 
disease on teeth, jaws and bones (Smith ct al. 1988). The 
presence of some diseases in the past population can be only 
assumed using a present day population, living in a similar 
environment, as a model. 

Fractured bones and skull vaults and depressions in the 
skull vaults are evidence of trauma (Figures 1 ,2), though 
habits such as preventing the dead man or woman from re- 
turning to life by throwing stones into the grave may explain 
some traumatic changes which might have been inflicted 
after death. 

A woman was buried at the moment of childbirth. A de- 
pression across her forehead was considered a fatal blow — 
the most probable reason being euthanasia (Pounder et al. 




Figure 2. Skull of adult female. No. 1 10, in situ 
in grave from trench A, Roonka, showing de- 
pression over frontal bone following a blow by a 
narrow object causing fracture. Photograph by 
Lloyd Chilman. 




Figure 3. Skull of 5-year-old child with cra- 
niosynostosis and fracture of right temporal 
bone. Fine pitting on parietal and occipital 
bones. Grave No. 77, Roonka. 



1983). Various pathological changes were found, such as an 
osteoma in the mandible in an old person, premature closure 
of all skull sutures (Simpson et al. 1983-1984; Prokopec et 
al. 1985) (Figure 3), arthritic changes in joints, signs of 
inflammatory processes on bones, an open sacral canal, and 
yaws or other trepanarid infections (Figures 2-7). It may be 

Zagreb Faleupulhology Symp IVSS 



\ 



Analysis of skeletal remains from Roonka, South Australia • 153 




Figure 4. Osteophytosis especially of upper 
margins of upper lumbar vertebrae. Grave No. 
85, Roonka. 




Figure 6. Open neural channel in sacrum. Tomb 
No. 61, Roonka. Male, mature. 







Figure 5. Compression fracture of body of T9 
and accentuated thorax curvature. Fusion of all 
units through coalescence of osteophytes and ap- 
ophyseal facets: T9/10, TlO/11, Tll/12 and 
T12/L1. Ankylosing spondylitis? Tomb No. 80, 
Roonka. Male, mature. 




Figurk 7. Lytic lesion with rugged edges and 
stellate scars on frontal bone due to treponarid 
infection yaws? Tomb No. 18, Roonka. Male, 
adult. 



Zagreb Paleopathology Symp. I9HH 



154 • Miroslav Prokopec and Graeme L. Pretty 





FiGURF 8. Enamel hypoplasia in upper incisors and canines 
and overbite in adult female. Tomb No. 1 10, Roonka. 



Figure 10. Shovel-shaped incisors and tuberculum dentale 
on left central upper incisor in juvenile individual male? 
Tomb No. 13A, Roonka. 





Figure 1 1 . Compressed front teeth crowding in juvenile individual 
male? Tomb No. I3A, Roonka. 



Figure 9. Thickening of diploe of frontal bone 
14 mm thick. Tomb No. 7, Roonka. Female, 
adult. _^_^ 

said that these features, present in populations all over the 
world, connect the Australian Aboriginals with other popula- 
tions(Rochlin 1965;Sandison 1973). Evidence of nutritional 
and metabolic disorders were found in some bones and teeth, 
such as fine pitting on the bone surface (Figure 2), enamel 
hypoplasia in front teeth (Figure 8), and thickening of the 
diploe of the frontal bone (Figure 9). 



GENETICS 

Inborn anomalies found in Roonka include supernumerary 
cusps on molars, shovel-shaped incisors, tuberculum dentale 
(Figure 10), protruding lower jaw (underbite), aplasia of lat- 
eral incisors, and other features. These are also found in 
every population in the world, sometimes perhaps with dif- 
ferent frequencies. 

Crowded teeth in lower jaws were quite frequent (28%) in 
the Roonka adult population (Figure 1 1 ). Heavy stress on the 
teeth since childhood may be blamed for this, since pressure 
acts in the direction from the molars toward the front teeth. 

Zagreb Paleopalhology Symp 1988 



Analysis of skeletal remains from Roonka, South Australia • 155 




Figure 12. Horizontal abrasion of crowns of all teeth in 
maxilla with secondary dentine. Note concavities of surface 
of tooth crowns. Tomb No. 50. Roonka. Male, mature- 
senile. 




Figure 13. High-grade attrition of crowns of all teeth in 
maxilla with open root cavities of some teeth. Helicoidal 
form of attrition. Tomb No. 61, Roonka. Male, senile. 



Genetically minded dental specialists explain it by indepen- 
dently inherited tooth size (broad teeth) and independently 
inherited mandible size (narrow mandibles). This phenome- 
non discovered in the Roonka population may contribute to 
discussions on the yet unknown origin of Aboriginals in 
Australia. It would mean that more than one strain of people 
were present in their ancestry — apparently a gracile and a 
robust type. 

CULTURE 

Culture has many facets. It is responsible for the behavior of 
the people, and to a certain extent it influences also their 
bodies. In the Roonka population the following features may 
be viewed as a sequence of cultural influences: deep abrasion 
of the crowns of the teeth (horizontal, helicoidal, interproxi- 
mal) (Figures 12-15), ritual evulsion of one or two upper 
central incisors (Figure 16), and ear exostosis (thickening of 
the external auditory canal bone), explained by otolaryngolo- 
gists as a reaction of the bone (periosteum) to cold tempera- 
ture and frequently found in swimmers and divers (Hrdlicka 
1935). It has been found in male skulls only (Figure 17). 

According to Campbell (1925), the habit of ritual tooth 
evulsion existed only in North and Central Australia (Figure 
16). Roonka revealed that this ritual was practiced also in the 
south of the continent for thousands of years. Skulls with 
evulsed central incisors were found even in the oldest graves 
(Campbell and Prokopec 1984). 

Roonka showed that before Europeans came, the people 
were probably completely free from caries. This does not 
mean that they did not suffer from other gingival and dental 
diseases and discomforts. The principal problems were due 
to extensive abrasion of crowns. Despite the formation of 
secondary dentine which developed in the abraded parts of 

Zagreb Paleiipalhiilofiy Symp lyXH 



the crowns (Figure 18), deep abrasion led in some instances 
to penetration into the tooth cavity. As a rule bacterial infec- 
tion followed and led to periapical inflammations and ab- 
scesses (Figure 19). 

Food preparation over an open fire (during which ashes 
and sand inevitably got into the food) is probably the main 
reason for tooth abrasion. The habit of chewing herbs and 
leaves of alkaloid-containing plants mixed with ashes as well 
as the presumed habit of rubbing teeth of the lower jaw 
against those of the upper jaw in the absence of food could 
also hasten the process of tooth abrasion. 

Another important agent which leads to dental deteriora- 
tion is using teeth as tools in manufacturing weapons and 
otherobjectsofdaily use (Figure 15). Even stone implements 
were sometimes retouched by teeth according to Barrett 
(pers. comm.) (Prokopec 1979). 

RECONSTRUCTION OF FACE FROM SKULL 

A drawing or photograph of a skull may serve as a basis for 
two-dimensional face reconstruction using the method of 
Galina Lebedinskaya. In order to reconstruct the face prop- 
erly, the skull should be intact and complete, in particular 
with respect to the preservation of the nasal bones and the 
anterior nasal spine (Sj0vold 1981). Any method of facial 
reconstruction is always associated with some inaccuracy. It 
is important to make allowances and adjustments for age of 
the person in question. A method of supcrprojection of a 
photograph of a man or woman belonging to the same popu- 
lation over a skull may show the probable appearance of the 
dead person. This is only the ca.se when the skull and photo- 
graph match satisfactorily in a .scries of well-identified an- 
thropometrical points on the skull and face and in a series of 
facial features and contours (Prokopec 1987). Photographs of 



156 • Miroslav Prokopec and Graeme L. Pretty 




Figure 14. Horizontal and interproximal attrition of 
right M 1 and M 2 in mandible, Tomb No. 87, Roonka. 
Female, mature. 




Figure 15. High-grade attrition with tilted left upper 
M 1 . Buccal margin of teeth is more aflected by attri- 
tion. Tomb No. 87, Roonka. Female, mature. 




Figure 16. Ritual evulsion of right upper central and 
lateral incisors. Healed tooth sockets. High attrition in 
remaining teeth. Enamel hypoplasia. Alveolar bone 
resorption. Tomb No. 23. Roonka. Male, mature. 

Zafireh Pciieopathnloi>\ Svmp. 198H 



Analysis of skeletal remains from Roonka, South Australia • 157 





Figure 18. Peglike right upper tliiid iiK)lar. scLoiidary dentin on the 
crowns of M 1 and M 2. Tomb No. 96, Roonka. Female, mature. 



Figure 17. Auditor) exostosis posterior. Both 
sides of skull affected. Tomb No. 3, Roonka. 
Male, senile. 



Figure 19. Considerable wear of tooth crowns with an 
open pulp cavity in first left lower molar, leading to an 
abscess. Tomb No. 23, Roonka. Male, mature. 




Aboriginals from the Port Lincoln Aboriginal Reserve in 
South Australia taken in the last century were used for super- 
projection over some of the Roonka skulls. In one instance an 
oil painting of an Aboriginal chief was matched with a skull 
from one of the status graves from trench A from the Roonka 
Flat. 

Conclusions 

Anthropological analyses on a sample of human skeletal ma- 
terial from an archeological site (Roonka) in South Australia 
shed light on demographical structure, health status, genet- 
ics, culture, and probable way of life of the people who 
inhabited the site for at least 7000 years before the arrival of 
the first European settlers. The buried people belonged to a 
basically similar physical type throughout the time period. 
Three different methods of face reconstruction from skulls 
were used in an attempt to restore the probable appearance of 
some of the buried persons. 

Zagreb Paleopathotogy Symp. t9Sft 



Their mean stature and mean age at death are much lower 
in comparison to present-day standards. On the other hand, 
child mortality was much higher but consistent with the so- 
ciety of hunters and gatherers and their harsh way of life. 
Women and babies were always at risk at childbirth while 
males died frequently in fights. Diseases which leave marks 
on bones were present as in other societies, not only in 
nomads. Fine pitting in a skull of a child indicates the pres- 
ence of anemia, and several instances of enamel hypoplasia 
bear evidence of nutritional disorders in early life. Caries was 
rare or absent , though deep abrasion of teeth and lack of oral 
hygiene caused trouble and discomfort. Contrary to literary 
sources the Roonka material showed that ritual evulsion of 
upper central front teeth was performed in South Australia 
for at least 7000 years. 

Survival of the Roonka population under conditions simi- 
lar to those faced by paleolithic hunters and gatherers for 
such a long time is the best proof of a functioning society 
fully adapted to the given environment. 



158 • Miroslav Prokopec and Graeme L. Pretty 



Acknowledgments 

Grateful acknowledgment is made to the South Australian 
Museum. Adelaide, to the Australian Institute for Aboriginal 
Studies. Canberra, and to the Institute of Hygiene and Epi- 
demiology, Prague, for their support, and to Lloyd Chilman 
for the photograph in Figure 2. One of the authors (M.P. ) 
expresses his thanks to the Smithsonian Institution, which 
enabled him to study human osteological material in the 
collections of the U.S. Museum of Natural History in Wash- 
ington, D.C. Further support to G.L.P. was provided by the 
Australian Research Grant Scheme. Sir Mark Mitchel Foun- 
dation, Potter Foundation, Sunshine Foundation, and Utah 
Foundation. All specimens illustrated herein are courtesy of 
the South Australia Museum. 

The authors are grateful to Colin Cook. Chairman. Gerard 
Community Council, and Valerie Power. Community Ad- 
viser, Point Macleay Community Council, for their support 
to the Roonka research project and interest in its results. 



Literature cited 

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Span and Mortality. Budapest: Akademiai Kiado. 

Brothweli. D.R. 1963. Digging up Bones. London: British Muse- 
um of Natural History. 

Campbell. AH., and M. Prokopec. 1984. Antiquity of Tooth Avul- 
sion in Australia. Artefact. 8:3-9. 

Campbell. TD. 1925. Dentition and Palate of the Australian Ab- 
original. Adelaide. Australia: Hassell Press. 

Hrdlicka. A. 1935. Ear Exostoses. Smithsonian Miscellaneous Col- 
lections. 93:1-100. 

1947. Practical Anthropometry, T.D. Stewart, ed. Phila- 
delphia: Wistar Institute of Anatomy and Biology. 

Krogman. W.M. 1962. The Human Skeleton in Forensic Medicine. 
Springfield. 111.: Charles C Thomas. 

Lamach, S.L., and L. Freedman. 1964. Sex Determination of Ab- 
original Crania from Coastal New South Wales. Australia. Rec- 
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Martin. R.. and K. Sailer. 1957. Lehrbuch der Anthropologie in 
systematischer Darstellung. Stuttgart. Germany: G. Fischer Ver- 
lag. 

Pounder. D.J.. M. Prokopec. and G.L. Pretty 1983. A Probable 



Case of Euthanasia amongst Prehistoric Aborigines at Roonka, 
South Australia. Forensic Science International. 23:99-108. 

Pretty, G.L. 1977. The Culture Chronology of the Roonka Flat. A 
Preliminary Consideration. In R.V.S. Wright. ci\.. Stone Tools as 
Cultural Markers: Change, Evolution and Complexity. 228-331 . 
Canberra: Australian Institute for Aboriginal Studies. 

Prokopec. M. 1979. Demographical and Morphological Aspects of 
the Roonka Population. Archaeology and Physical Anthropology 
in Oceania. 14:1 1-26. 

1987. FT)er die Rekonstmktion des Gesichtsausdruckes 

alter Slaven. Acta Musei Nationalis Pragae, Line B. Natural 
Sciences. 43:203-205. Tables 9-12. 

Prokopec. M.. D. Simpson. L. Morris, and G.L. Pretty. 1985. 
Craniosynostosis in a Prehistoric Aboriginal Skull: A Case Re- 
port. Ossa. 9-11:111-118. 

Rochlin. D.G. 1965. Diseases of Ancient Man. Moscow: Nauka. 

Sandison. A.T 1973. Disease Changes in Australian Aboriginal 
Skeletons. Australian Institute of Aboriginal Studies Newsletter, 
3:20-22. 

Simpson. D.. M. Prokopec. L. Morris, and G.L. Pretty. 1983- 
1984. Prehistoric Craniostenosis: A Case Report. Records of the 
Adelaide Children s Hospital. 3:163-168. 

Sj0vold, T 1981. Arpas Anatomical Method for Face Reconstruc- 
tion. Ossa. 7:203-204. 

Smith. P.. M. Prokopec, and G.L. Pretty 1988. Dentition of a 
Prehistoric Population from Roonka Flat. South Australia. Ar- 
chaeology in Oceania. 23:31-36. 

Stewart, T.D. 1952. Hrdlicka s Practical Anthropometry. Phila- 
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Stioukal, M., and H. Hanakova. 1971. Anthropology of an Early 
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Trotter, M.. and G.C. Gleser. 1952. Estimation of Stature from 
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Summary of audience discussion: The tooth crowding demon- 
strated is interesting because Dr. Corruccini's work in India sug- 
gests a decreased frequency of tooth crowding in populations con- 
suming a diet requiring vigorous chewing, the frequency rising later 
following the introduction of a softer diet. No such pattern, how- 
ever, was demonstrable in this population. The two cranii revealing 
changes suggestive of treponematosis failed to demonstrate perios- 
titis of the tibia or other long bones. 



Zagreb Paieopaihotogy Symp. 1988 



Tuberculosis 



Tuberculosis in the Americas: 
Current perspectives 



Jane E. Buikstra and Sloan Williams 



Histologic studies of the hydrated lungs showed a large amount of fibrous tissue 
in the right apex. Dr. Garcia-Frias concluded the combination of spine and lung 
disease showed that tuberculosis is the most likely diagnosis, and the present 
writer agrees, although other conditions cannot be ruled out. 

—Morse 1961:497 

The case presented herein should conclusively end this dispute and remove doubt 
that tuberculosis did exist in the Department of lea in southern Peru, South 
America, hundreds of years before the coming of any European to the Americas. 

— Allison etal. 1973:985 



Rchydrated soft tissue from South American mutnmies has 
proved crucial in the ongoing debate concerning the presence 
of a "tuberculosis-like" pathology in the prehistoric Amer- 
icas. In the 1961 review cited above, Morse, while skeptical 
of North American skeletal examples attributed to tuber- 
culosis, was willing to accept tuberculosis as "the most likely 
diagnosis" for mummified Peruvian remains reported by 
Garcia-Frias in 1940. Even though he found the tissue evi- 
dence convincing, Morse (1961:497) was led to question the 
archeological context for these materials and thus concluded 
that a pre-Columbian attribution was not secure. 

Further investigations of mummified soft tissue, reported 
by Allison and co-workers in 1973 and 1981 , provided con- 
vincing histologic and contextual data. The 1973 report de- 
scribed acid-fast bacilli. Pott's disease, and a psoas abscess 
in the remains of a Nazca child, dating to approximately a.d. 
700, and thus established with certainty the presence of a 
tuberculosis-like pathology in the prehistoric Americas. 
Even Morse was led to alter his stance, remarking that al- 
though he generally agreed with Allison and co-workers con- 
cerning the diagnosis, "there should have been many more 
cases of suspect tuberculosis than have been found to date" 
(1978:53). 

Recent studies of pre-Columbian tuberculosis, as indi- 
cated in Table 1 , are rapidly providing the "many more cases" 
called for by Morse. Most examples cited in this survey are 
descriptive reports of skeletal lesions from North American 
series, including isolated cases as well as profiles from larger 
samples. Both isolated examples and frequency data are im- 

Zagreh Pateopatholof^y Symp. 1988 



portant in establishing the probable antiquity and distribution 
of the pathology, although for issues relating to community 
health and quality of life, the large-scale series are most 
useful. In South America, Allison and co-workers (1981, 
1984) have documented additional cases from Peru and 
Chile. Surveys of large Andean skeletal samples to establish 
lesion form and distribution in a manner suitable for com- 
parison with North American data sets have, however, yet to 
occur. The ultimate goal of this paper is, therefore, to estab- 
lish lesion patterning within a large prehistoric Peruvian skel- 
etal sample and thus provide a data base for comparison with 
North American examples. 

Related topics addressed within the past few years include 
the persistent question of origins. The argument that tuber- 
culosis could only have developed in the context of domestic 
animals as hosts (Cockburn 1963) has proved unconvincing 
in the North American example. The possibility that atypical 
mycobacteria should be implicated has been raised (Clark et 
al. 1987; Eisenberg 1986; Klepinger 1982) and will be dis- 
cussed in detail below. 

A novel approach, recently applied to the study of pre- 
historic tuberculosis, is the development of mathematical 
models for the spread of disease. Although this strategy has a 
lengthy history within the medical sciences (Grigg 1958; 
Waaler et al. 1962), it has been developed only recently 
within paleoepidemiology (McGrath 1986,1988; Milner 
1980). As this form of investigation holds promise for estab- 
lishing expectations and comparabilities across time and 
space, it also will be reviewed here. 

161 



162 



Table 1. Recently reported cases of skeletal tuberculosis from North America 



Sue 



Local ion 



Period 



Pathology 



Reference 



Moundville 


Alabama 


Miss. A.D. 
1050-1550 


Irene Md. 


Georgia, north 


Miss. A.D. 




of Savannah 


1100-1400 


Parkin 


Cross Co., AR 


Late Miss. 


Daw's Is. 


Beaufort Co., 
SC 


3300-3700 



Turpin site SW Ohio 

Arnold Cumberland, TN 

Averbuch Nashville, TN 



Norris Farm Cent. Illinois 
#36 

Kane Mounds Am. Bottom 



Ball Site Lake Ontario; 

Iroquois ossuary 

Uxbridge Ontario 
(ossuary) 

Woodlawn site SE Saskatchewan 

Jamestown N Dakota 
Mounds 



Vert: M 25-29.9, 2F 30-39.9; Powell 1988 
ribs: 2 juv, 8 Y-M adults 
(13/564)' 



2 juv, 4 y ad, 4 40-50 yr 
F;M 2:1 (10/265)° 

F 35-40 yr, F 17-25 yr 
(2/16) 



A.D. 1 125-1425 F 20-25 yr, 2M 35+ yr, 2F 
Ft. Ancient 16-18 yr, F adult 

(5/291) 

-A.D. 1200 F y adult 

A.D. 1275-1400 M:F2:1 



Oneota 
-A.D. 1300 



(32/264) 
F y ad, F m ad 
A.D. 1590-1600 ±11 yr(!/6) 



Miss. A.D. 
1150-1250 



Powell 1989 



Murray 1985 



Rathbun et al. 1980 



Katzenberg 1977; Perzigian 
and Widmer 1979; Widmer 
and Perzigian 1981 

Widmer and Perzigian 1981 

Eisenberg 1986; Kelley 
and Eisenberg 1987 

Milner et al. 1988 



Milner 1982 



Melbve 1983 



A.D. 1490±80 

A.D. 1080±139 
A.D. 930±70 



1 3-5 yr, 2 6-16 yr, 5 17-25 Pfeiffer 1984 
yr, 18 ad 



F ±45 yr 
M 35-45 yr 



Pueblo Bonito NW New Mexico A.D. 828-1 130 ±9 yr 



Walker 1983 

Williams and Snortland- 
Coles 1986 

Morse 1969; El-Najjar 1979; 
Ortner and Putschar 1981 



Chavez Pass N Arizona 

AZ-J-549 NE Arizona 

Point of Pines SW Arizona 

Near La7602 Tocito, NM 



A.D. 900- 1 100 2M 20-30 yr, F 25-35 yr(?) El-Najjar 1979 
M 40-50 yr (?) 



A.D. 875-975 F 16-18 yr 

A.D. 1285-1450 F y ad 
A.D. 900-1300 4-5 yr 



Sumner 1985 

Micozzi and Kelley 1985 

Fink 1985 



a. Figures include only those individuals with significant numbers of observable ribs and/or vertebrae 
(Powell pers. comm.). 



Zagreb Paleopathology Symp I98K 



Tuberculosis in the Americas: Current perspectives • 163 



Modeling expectations for prehistory 

McGrath ( 1986, 1988) has developed a simulation approach 
to modeling expectations for the spread of tuberculosis with- 
in prehistoric communities. She chose as a basis for her 
analyses a diachronic sequence of three paleopopulations 
from west-central Illinois: Middle Woodland (150 b.c.-a.D. 
400). Late Woodland/Emergent Mississippian (a.d. 400- 
1050), and Mississippian (a.d. 1050- 1 150). This study area 
was selected for its abundant archeological data, as well as 
the fact that late prehistoric skeletal samples (Buikstra 1977; 
Buikstra and Cook 1 978 ,1981) show evidence of tuberculo- 
sis-like pathology. Estimates of regional population aggrega- 
tion and disease transmissibility are based upon current 
archeological wisdom concerning population size and settle- 
ment distributions. As emphasized by McGrath, the goal was 
to demonstrate the value of simulation for paleoepidemio- 
logic study with the expectation that additional investigations 
of regional prehistory will necessitate redefinition of basic 
parameters (McGrath 1986.1988). 

McGrath's stochastic adaptation of the Reed-Frost model 
generates epidemic disease curves based upon specified as- 
sumptions concerning the behavior of tuberculosis in recent 
human groups. Communities were modeled either as small, 
stable units arranged linearly along the Illinois River (Middle 
and Late Woodland) or as scattered farmsteads (Mississip- 
pian). Regular interaction occurred between neighboring 
communities only, the Late Woodland contact pattern includ- 
ing more groups than the Middle Woodland example. Twice a 
year Middle Woodland communities converged on a local 
"ceremonial center"; Mississippian groups traveled twice a 
year to Cahokia, a large urban complex to the south. 
McGrath's estimated population parameters are presented in 
Table 2 (after McGrath 1988:489). Two levels of regional 
population numbers and settlement size are developed for 
each model. 

McGrath's simulation tests the spread of tuberculosis 
within the hypothetical region over a 100-year period. Age- 
specific mortality rates are developed based on contemporary 
expectations for tuberculosis and a life table constructed 
from archeological data. Disease prevalence, the infectious 
proportion of the population, and mortality patterning are 
modeled. In all cases, with the exception of the second Late 
Woodland (LW2) model, the simulated populations experi- 
ence severe, drastic disease stress and become extinct within 
the 100-year period. In the LW2 example, the pathogen be- 
comes extinct. Again, with the exception of LW2, all groups 
show evidence of high disease prevalence — 100% for Mis- 
sissippian and 30-40% for the first Late Woodland and both 
Middle Woodland models. 

McGrath (1988:494) concludes that the key variable influ- 
encing the fate of these simulated populations is effective 
population size: 



TaBLL; 2. McCiralh's ( l'J88:489) population models 

Run Pop. Pop. Settle- Effeclnt- 

siz^ density ment pop. 
size 



MWl 


4<).35 


1.60 


35 


l.S-KJ 


MW2 


1345 


0.46 


10 


440 


LWl 


15855 


5.37 


120 


108(f /48(f 


LW2 


2655 


0.71 


20 


18tf/8tf 


Ml, 2 


2168 


0.71 


30 


45045, 12045 


M3, 4 


1088 


0.35 


15 


44022, 11022 



a. Base population si/c is used lo generate 
settlement size. Settlement size is multiplied by 
number of .sites, then number of introduced cases 
of tuberculosis is added lo gel final population 
size. Middle and Lale Woodland models have 15 
introduced ca.ses; MissLssippian models have 8 
introduced cases. 

b. Effective population size for upland 
communities. 



c. Effective population 
communities. 



size for valley 



Effective population size appears to be more important than 
all the other factors that influence disease occurrence. In 
other words, regardless of group size, number of neigh- 
bors, population age structure, or regional population size 
it appears to be effective population size that determines the 
course of the epidemic. Regional population size and group 
size seem to affect the speed with which the disease is 
spread and population declines, but effective population 
size determines whether decline occurs at all. 

McGrath further concludes that "a critical value of effec- 
tive population size that permits both the host population and 
the pathogenic organism to survive" exists somewhere in the 
range between 180 and 440 individuals (McGrath 1988:494). 
This statement holds implications for paleodemographic re- 
constructions in situations where an ancient tuberculosis-like 
disease is documented. Her work also underscores the impor- 
tance of social and cultural factors that influence population 
interaction in disease transmission. 

Tuberculosis-like lesions in the Mississippian skeletal se- 
ries from west-central Illinois have, however, been amply 
documented (Buikstra 1977; Buikstra and Cook 1978,1981). 
Obviously either McGrath's model is misspecified or the 
disease entity reflected in the osseous record was not behav- 
ing in the same manner as modem tuberculosis caused by 
Mycobacterium tiiherculosis. Changing temporal and geo- 
graphic expressions of disease caused by M. tuberculosis 
have, however, been described (e.g., Dubos 1965; Grigg 



Zagreb Pateopaihotogy Symp. 1988 



164 • Jane E. Buikstra and Sloan Williams 



1958). We therefore may simply be documenting a flexible 
host-parasite relationship. An alternative suggestion is the 
possibility that the prehistoric tuberculosis-like pathology 
described in Illinois and elsewhere in the Americas was 
cau.sed by a pathogen other than M. tuberculosis (Buikstra 
1981; Clark et al. 1987; Eisenberg 1986; Klepinger 1982; 
McGrath 1986,1988). 

Atypical /en vironmental mycobacteria 

Recently, Clark and co-workers ( 1987) have underscored the 
importance of considering mycobacteria other than M. tuber- 
culosis when assessing the impact and origins of the 
tuberculosis-like lesions of prehistoric tissues in the Amer- 
icas. 

What is known about the ecology of mycobacterial disease 
raises the possibilities that pre-Columbian "tuberculosis" 
was caused ( 1) by M. tuberculosis but in a population im- 
munized by exposure to environmental ("atypical") my- 
cobacteria; (2) by M. tuberculosis but a strain of low 
virulence; (3) by M. bovis transmitted by wild animals 
(e.g., butchering and tanning skins of infected bison), with 
infection resulting in self-limiting disease and long-lasting 
immunity; and/or (4) by one or more of the environmental 
mycobacterial species. (Clark et al. 1987:51) 

In general , individuals who commented on this manuscript 
commended the authors for emphasizing the dynamic nature 
of host-parasite relationships. The possibility that the en- 
vironmental mycobacteria are heavily implicated in late pre- 
historic populations from the Americas is, however, ques- 
tioned. Katzenberg (1987:52) and Klepinger (1987:52), for 
instance, emphasize that the prevalence of observed 
tuberculosis-iike pathology reported for late prehistoric pop- 
ulations in North America is consistent with an infectious 
disease spread by host-to-host transmission. The environ- 
mental pathogens are rarely, if ever, transferred between hu- 
mans (Lincoln and Gilbert 1972; Sommers 1979; Wolinsky 
1979). 

Steinbock (1987:56) points out that the calcified Ghon 
complexes reported by Allison and co-workers (1981) for 
two prehistoric and one colonial period South American re- 
mains are simply not consistent with disease caused by en- 
vironmental mycobacteria. Even though the environmental 
mycobacteria could have produced the acid-fast reaction 
noted by Allison and co-workers (1973), he considers the 
calcified Ghon complex specific to tuberculosis. 

Kelley and Eisenberg have suggested that the skeletal le- 
sions produced by the environmental mycobacteria are "es- 
sentially identical" to those produced by M. tuberculosis 
(1987:94). A similar argument is offered by Clark et al. 
(1987:48-49). This generalization would appear, however, 
open to debate. In fact, the sources cited by Kelley and Eisen- 
berg in support of this statement are either silent (Good 1 980) 
or rather ambiguous concerning the form and distribution of 



skeletal lesions. Wolinsky (1974:645) notes that "several 
cases of M. kansasii disease of the bones and joints are on 
record" but does not provide a comparison of the skeletal 
lesions characteristic of tuberculosis and those caused by the 
environmental pathogens. In more recent work, Wolinsky 
(1979) reviews a number of cases of both disseminated and 
localized infections caused by the atypical mycobacteria. In 
so doing, he emphasizes occupational trauma as a major 
factor influencing the distribution of skeletal lesions. Deep 
hand infection is emphasized, with fewer cases reported for 
the wrist, hip, knee, spine, and calcaneum. This review indi- 
cates that while the form taken by specific skeletal lesions 
may resemble tuberculosis, neither lesion location nor age- 
specific patterning mirrors that expected for tuberculosis 
(Wolinsky 1979). 

In fact, when case studies are reviewed, it appears that 
both age-specific patterning and intraindividual lesion dis- 
tributions for environmental mycobacterial infection difler 
from tuberculosis (Ellis 1974; Halla et al. 1979; Halpem and 
Nagel 1978; Lakhanpal et al. 1980). Vertebrae may be af- 
fected, but there is no convincing evidence of a tuberculosis- 
like predilection. Lakhanpal and co-workers, for instance, 
emphasize that the clinical, radiologic, and histologic ap- 
pearance of the lesions caused by M. kansasii is distinctive 
from that of tuberculosis. "It seems as if the basic pathology 
of lesions caused by these organisms is different from the one 
caused by Mycobacterium tuberculosis" (Lakhanpal et al. 
1980:473). 

Lincoln and Gilbert ( 1972:697) point out that "disease of 
only one area of the skeletal system was reported infre- 
quently" in their survey of children suffering from disease 
caused by acid-fast bacilli other than M. tuberculosis and M. 
bovis. They conclude that the disseminated mycobacterioses 
attributed to the atypical forms most closely resemble a "ma- 
lignant type of reticuloendotheliosis" (Lincoln and Gilbert 
1972:708), not tuberculosis. 

For individual lesions, however, bony involvement in dis- 
ease caused by environmental mycobacteria could mimic 
expectations for osseous tuberculosis (e.g., a 14-year-old 
male with lumbar vertebral and sacroiliac involvement; Ellis 
1974). Even so, it is difficult to disagree with Steinbock's 
comment: "It is inconceivable that one of these forms |of 
environmental mycobacteria] could be the pathogen for pre- 
Columbian tuberculosis" (1987:56). 

The geographic distribution and balanced gender ratios 
observed in North American prehistoric samples would also 
argue against acquisition through butchering or other occu- 
pations that would place an individual at risk for environmen- 
tal mycobacteria, as Clark et al. (1987) have argued. Thus, 
although it certainly is possible that these pathogens may 
have caused a few of the lesions reported in prehistoric series 
and they may likewise have influenced the expression of 
disease in certain individuals, it is unlikely that they can be 
seriously implicated in the vast majority of prehistoric exam- 
ples. 

Zagrrb Paleopathology Symp. 1988 



Tuberculosis in the Americas: Current perspectives • 165 



The distribution and prevalence of the tuberculosis-like 
pathology recognized in the Americas during pre-Columbian 
times may, however, have been influenced by the environ- 
mental mycobacteria. In this light, it is instructive to note that 
when the larger skeletal series represented in Table 1 are 
considered, relatively low population frequencies for tuber- 
culosis occur in the southeastern United States, at Irene 
Mound and Moundville. Recent laboratory surveys of isolate 
distribution and frequency for the nontuberculous mycobac- 
teria describe the Southeast as having high isolate fre- 
quencies for M. avium. M. fortuitum, M. kimsasii, and M. 
scrofulaceum (Falkinham et al. 1980; Good 1980; Good and 
Snider 1982). Inreaction to the Clark etal. (1987) argument, 
Powell has implicated cross-immunity due to the presence of 
environmental mycobacteria to explain the "low visibility" 
of tuberculosis at Moundville (Powell 1988:180). Although 
incomplete archeological recovery may be cited in the 
Moundville example, the possibility that the distribution of 
atypical mycobacteria may have influenced the prevalence of 
prehistoric tuberculosis-like pathology should be considered 
in studies of ancient disease in the New World. 

Clark et al. (1987) call attention to the presence of less 
virulent strains of tuberculosis that occur in India ("south 
Indian variant"), in other parts of south and southeast Asia, 
and in Africa. Such geographic variability underscores the 
flexibility of the pathogen-host relationship and is a topic 
worth considering further. It would be of interest, for in- 
stance , to discover the degree to which osseous lesions devel- 
op in these nonvirulent, pervasive forms. Certainly extensive 
skeletal involvement has been reported for victims of tuber- 
culosis in India (Ganguli 1963). It would also be appropriate 
to implement McGrath's simulation approach using variables 
specified according to the parameters common to the less 
virulent forms. 

North American model 

The recent case studies of the North American tuberculosis- 
like pathology reported in Table I expand the earlier sum- 
mary presented by Buikstra (1977:326). Although certain 
examples fit expectations more tightly than others, it appears 
that there is now sound evidence for disease in eastern United 
States population centers such as the Cumberland Basin, the 
central Mississippi valley, and southern Ontario. Typical 
skeletal expressions of tuberculosis-like pathology are de- 
scribed in multiple individuals from several sites, including 
Norris Farm #36, Schild Mississippian Cemetery, Mound- 
ville, Averbuch, and in the Ontario ossuaries reported by 
Hartney (1981) and Pfeiffer (1984). With the exception of 
an isolated lesion in a thoracic vertebra from the Serpent 
Mounds (Anderson 1968), a single case from an Archaic 
shell mound (Rathbun et al. 1980), and an Illinois example 
from uncertain context reported by Morse (1969:502) and 
Ortner and Putschar (1981:173), these skeletal series post- 
date A.D. 1000. Although uneven sex ratios occur in certain 

Zagreb Paleopathology Symp. 1988 



contexts, both males and females, as well as all age groups, 
are represented. In the Schild and the Averbuch cases, the 
classic Pott's disease occurs in young adults. Healed cases, 
as at Irene Mound (Powell 1990), tend to be found in older 
individuals; disease active at the time of death is associated 
with juveniles and younger adults. 

Plains and the Southwest examples have increased in re- 
cent years. Although the sample size is small, they neverthe- 
less suggest a slightly earlier presence than in the eastern 
examples. Only one, however, cleariy predates a.d. lOCK): 
the Kayenta adolescent reported by Suinner (1985). 

The frequency data for the North American skeletal series 
is somewhat enigmatic when viewed from the perspective of 
modem clinical samples. When the larger, best preserved, 
and well-excavated series reported in Table 1 and in Buikstra 
(1977) are considered, percentage values range from the 
Moundville (5.2%), Irene Mound (5.7%) and Schild Ceme- 
tery (6.7%) figures to 12.1% for the Norris Farm #36 site. 
(The Averbuch frequency may also be as high as 6. 1%, but 
this is difficult to interpret since Kelley and Eisenberg (1987) 
apparently include individuals with periosteal remodeling in 
long bones in the absence of other pathognomic lesions. ) The 
oft-cited figures of 5-7% bony involvement in modem hos- 
pital samples (Steinbock 1976:175,1987:55), even tempered 
by Kelley and Micozzi's (1984) observations in the Hamann- 
Todd collection, suggest that virtually every member of these 
late prehistoric communities had primary exposure to tuber- 
culosis, as suggested by Klepinger ( 1987:52). In situations of 
extreme social and biological stress, such as that reported by 
Milner et al. (1988) for the Norris Fami #36 population, 
prevalence of chronic destructive disease appears to have 
been extreme. 

South America 

Allison and co-workers (1973; 1981) have reported a series 
of 12 remains from Peru and Chile that they consider to be 
expressions of tuberculosis. Of these, three (1981, cases 4,5 
and 9) could be postcontact. The diagnosis of the cranial 
granuloma in case 1 1 (Allison et al. 1981:51) is sufficiently 
problematic that it will also be excluded from discussion 
here. Of the remaining eight prehistoric examples, four show 
skeletal involvement, three without confirming soft tissue 
pathology. The remaining four are diagnosed based upon 
healed Ghon complexes (cases 2 and 8) and cavitary pulmo- 
nary disease in association with acid-fast bacilli (cases 6 
and 7). 

The examples with skeletal involvement include one juve- 
nile 8- 10 years of age. two males: one listed as 4 1 -H years of 
age and another "adult," and an isolated female 40 years old. 
Those diagnosed through soft tissue include the 8-IO-year- 
old juvenile with Pott's disease, a 14-year-old female, a male 
adult, and two females: 50 and 56+ years old. Thus, there 
are two juveniles and four middle-old adults. Individuals 
dying within the young adult years are conspicuously absent 



166 • Jane E. Buikstra and Sloan Williams 



Table 3. Age distributions for tubercular and nontubercular 
remains from the Estuquina site 



Table 4. Age distributions for tubercular and nontubercular remains 
from the Estuquina site 



Age range 


No. in total 


No. in group with 


No. in affected 


Age Range 


No. in total 


No. with lesions 


No. with 




sample (%) 


>5 \<enebnie (%) 


sample (%) 




sample (%) 


other than primary 
rib involvement (%) 


primary rib 
involvement (%]^ 




151.00 (36) 


90.00 (.39) 


5.00(14) 


b-9.9y 










10- 19.9 y 


59.00 (14) 


36.25 (16) 


3.00 ( 8) 


b-9.9y 


151.00 (36) 


3.00 (16.7) 


2.00 (10.5) 


20-29.9 y 


63.00 (15) 


36.75 (16) 


71.50(31) 


10- 19.9 y 


59.00 (14) 


1.00 ( 5.6) 


2.00 (10.5) 


30-39.9 y 


45.25 (11) 


21.00 ( 9) 


4.20 (11) 


20-29.9 y 


63.00 (15) 


7.00 (38.9) 


4.50 (23.7) 


40-49.9 y 


45.50(11) 


23.00 (10) 


4.90(13) 


30-39.9 y 


45.25 (11) 


3.00 (16.7) 


1.20 ( 6.3) 


50+ y 


50.25 (12) 


26.00 (11) 


8.40 (23) 


40-49.9 y 


45.50(11) 


1.00 ( 5.6) 


3.90 (20.5) 




414.00 


233.(X) 


37.00 


50+ y 


50.25 (12) 
414.00 


3.00 (16.7) 
18.00 


5.40 (28.4) 
19 00 













from this sample, thus contrasting with the pattern presented 
by the larger North American series. 

An isolated case of diffuse Pott's disease dated to 160 B.C. 
is the earliest example, followed by three adults from the 
Caserones site, dated to a.d. 290. These four examples are 
1500 to more than 2000 years old, much more ancient than 
Kelley and Micozzi imply in their discussion of the same 
material: "... these cases are all within about the last 1 ,000 
years" (Kelley and Micozzi 1984:385). Clearly, the evidence 
from South America suggests an earlier manifestation of the 
disease, though with a somewhat different age-specific ex- 
pression than that found in North America. 

Estuquina series 

The Estuquina site dates to approximately a.d. 1350 and is 
situated in the Moquegua valley at approximately 1000 m 
above mean sea level (Rice 1989). Located near the present- 
day town of Moquegua. in southern Peru, the site is situated 
on a ridge top and is fortified by stone walls. Three separate 
cemetery areas have been identified, with burials also occur- 
ring within domestic structures. Samples of both intact and 
disturbed tombs have been excavated, resulting in 414 indi- 
viduals from 244 tombs. Tomb contents and cemetery organ- 
ization have been described in detail by Williams et al. 
(1989). 

The demographic structure of the sample is presented in 
Table 3. along with the distribution of individuals showing 
skeletal evidence of tuberculosis-like pathology. For com- 
parative purposes, we also indicate the numbers of individu- 
als with five or more observable thoracic and lumbar ver- 
tebrae. Individuals presenting lesions are reported in detail in 
Appendix I . Table 4 differentiates those individuals with rib 
involvement from those with other tuberculosis-like lesions. 
In the latter group, vertebral involvement is typical for 
adults, with accompanying sacroiliac and paravertebral rib 
lesions in extreme cases. Also included are juveniles that 
present periostitic remodeling of the ilia in a manner similar 
to that reported for the Schild series (Buikstra and Cook 
1978,1981). 



a. One example of periosteal reaction on internal aspect of sternum 
(M6- 3269a) included here. 

The list of individuals with rib lesions (Table 4) includes 
both those cases which present only periosteal remodeling 
and those displaying primarily destructive foci. Resorptive 
rib lesions are the form commonly referenced in the medical 
literature (Rechtman 1929; Johnson and Rothstein 1952; Tat- 
elman and Drouillard 1953), while periosteal reaction is em- 
phasized by Kelley and Micozzi (1984) in their discussion of 
the Hamann-Todd series. 

Kelley and Micozzi (1984) argue that subtle periostitis on 
the internal aspects of ribs may be associated with pulmonary 
tuberculosis. They cite data from individuals in the Hamann- 
Todd collection who were diagnosed as either suffering from 
pulmonary tuberculosis or "tuberculosis." Most of their 
cases present periosteal reaction only, although in a few in- 
stances, more extensive, sharply circumscribed foci are re- 
ported. Kelley and Micozzi argue that these lesions develop 
as a result of extension from the lungs and pleura, citing 
clinical sources in support of this assertion. "That tubercle 
bacilli are capable of extending from the lung or pleura into 
the ribs has been well documented clinically (e.g. Rechtman 
1929; Johnson and Rothstein 1952; Jaffe 1972; and Anderson 
1976)." 

In fact, the two case studies in this reference list very 
clearly describe tubercular rib lesions which are attributed to 
hematogenous spread, not extension from the lung or pleura. 
The Rechtman (1929) article describes an infant whose 7th 
rib involvement developed after an earlier focus within the 
synovium of the knee. Hematogenous spread to the rib is 
posited. Johnson and Rothstein report three cases of rib in- 
volvement and conclude. "While the exact pathogenesis of 
these lesions is not certain, they are probably hematogenous 
in origin, differing in no way from tuberculous involvement 
of other bones. There is no evidence in any of our cases of 
extension from adjacent organs" (1952:880). Although Jaffe 
(1972: 1002) does state that proximity and extension explain 
rib lesions, it is clear that the two primary sources do not so 
argue, it should also be noted that examples of extension 
from paravertebral abscesses into the lung are commonly 

Zagreb Paleopathology Symp. 1988 



Tuberculosis in the Americas: Current perspectives • 167 



reported, as arc abscesses on the external aspect of the thorax 
(Hodgson et al. 1969; Yau and Hodgson 1968; Jaffe 1972; 
Johnson and Rothstein 19.'S2; Rechtman 1929), 

Most clinical experience with rib tuberculosis follows the 
pattern described by Tatelman and Drouillard ( 1953). These 
authors report four types of tuberculosis of the rib: ( 1 ) cos- 
tovertebral. (2) costochondral, (3) isolated body lesion, and 
(4) multiple cystic foci. In each case, destructive processes 
constitute the primary symptom, with the majority of the 
lesions involving the body. These resorptive foci follow the 
typical pattern for bone tuberculosis and are clearly dilTcrent 
from the mild periostitic response described by Kelley and 
Micozzi ( 1984). Certainly, the features described by Kelley 
and Micozzi may indeed reflect tuberculosis. Persons en- 
gaged in paleoepidemiological study should, however, also 
be aware of the patterns typically taken by the resorptive foci 
reptirted in the medical literature. 

Although Kelley and Micozzi (1984:386) correctly indi- 
cate that tuberculosis is the most commonly observed inflam- 
matory condition in the ribs, a differential diagnosis of rib 
lesions attributable to tuberculosis must consider other forms 
of pathology. For instance, Tatelman and Drouillard report 
that "tuberculosis is second only to metastatic malignancy as 
a cause of destructive lesions of the ribs" (1953:923). Thus, it 
is clear that metastatic processes must be considered in devel- 
oping a differential diagnosis of tuberculosis-like lesions in 
ribs. 

In discussing differential diagnosis, Kelley and Micozzi 
(1984:386) state: "Conditions to be considered in the differ- 
ential diagnosis of skeletal tuberculosis are actinomycosis, 
typhoid, pyogenic osteomyelitis and syphilis (Sinoff and Se- 
gal 1975)." Sinoff and Segal's article, entitled "Tuberculous 
osteomyelitis of the ribs: a case report," however, makes it 
clear that their primary concern is with manifestations in the 
rib. rather than "skeletal tuberculosis" in general, as sug- 
gested by Kelley and Micozzi. The full quotation from Sinoff 
and Segal reads: "The single most important differential di- 
agnosis (in rib tuberculosis) is metastatic carcinoma, but 
other possible diseases include: (i) actinomycosis, (ii) ty- 
phoid or paratyphoid osteomyelitis, (iii) pyogenic os- 
teomyelitis and (iv) syphilis" (1975:866). Thus. Sinoff and 
Segal are focusing upon tuberculous manifestations of the rib 
and emphasizing metastatic carcinoma. 

Kelley and Micozzi (1984:386) follow their listing of dis- 
eases appropriate for differential diagnosis in "skeletal 
tuberculosis" — actinomycosis, typhoid, pyogenic osteo- 
myelitis, and syphilis — with the statement. "However, none 
of these conditions commonly affects the ribs." This conclu- 
sion is remarkable since Sinoff and Segal (1975) are clearly 
concentrating upon forms of disease affecting the rih. And in 
fact, one of the conditions most likely to produce just the type 
of proliferative response described by Kelley and Micozzi is 
actinomycosis. Tatelman and Drouilard (1953:932) describe 
rib involvement in actinomycosis through direct extension 
from lung and pleural involvement, emphasizing productive 

2agnb Paleopathology Symp 1988 



changes due to this condition. A classic description derives 
from Edeiken (1981:792): "When the thoracic wall is af- 
fected, the ribs may show destruction, although they usually 
react with periosteal new bone formation and become thick 
. . . which, although not diagnostic of actinomycosis, is 
most suggestive." Clearly, actinomycosis and perhaps other 
related disease processes must be considered when periostitic 
reaction is observed on ancient ribs. Thus, while Kelley and 
Micozzi may be correct in attributing the mild periostitis 
observed in the Hamann-Todd series to tuberculosis, it is 
clear that conditions other than tuberculosis can produce 
periosteal reaction on ribs. 

The age profiles for the total Estuquina skeletal series and 
the subsample with more than five observable thoracic/lum- 
bar vertebrae (Table 3) do not differ significantly (Kolmo- 
gorov-Smimov test, D„ „ = 0.06; D^^, = 0.1 1 1; p > .05). 
For the purposes of further testing, the affected individuals 
are compared with the vertebrally observable subsample. 
The two subgroups, rib and nonrib. indicated in Table 4 do 
not differ significantly in age structure (D^, „ = 92; D^^,^ = 
142; p > .05). The total affected sample does, however, 
differ significantly in mortality experience from the larger 
Estuquina skeletal series (D,„ „ = 0.33; D^.„, = 0.29; p < 
.01). This difference is influenced primarily by the elevated 
numbers of affected individuals in the young adult and el- 
derly adult years. The former include active cases, while the 
latter comprise the more extreme and healed examples. Low 
visibility and perhaps low prevalence of bony involvement 
likely affect the figures for young juveniles. 

These results indicate that young adults are overrepre- 
sented in the affected sample, as they were not in the series 
reported by Allison et al. (1981). This apparent elevation of 
young adult morbidity, whether the full series or only that 
with more than five thoracic or lumbar vertebrae present is 
used for comparison, is expected for a tuberculosis-like 
pathology. The pattern is characteristic of the larger North 
American samples reported in Table 1 . 

An unusual feature of the Estuquina series is, however, an 
apparent skewed sex ratio. Although males are overrepre- 
sented in the full sample (99 males, 71 females), the affected 
adult sample presents a decidedly more extreme bias (19 
males, 7 females). When the tubercular sample is subdivided 
by area of involvement (Table 4), we find rib lesions in 8 
males and 4 females, while among the remainder, 12 males 
and only 3 females are affected. Two of the three females 
with classic Pott's disease are older individuals with extreme 
degeneration of the spine (M6-102la, M6-5390). A chi- 
square compari.son indicates that sex ratio of affected individ- 
uals is significantly different from the total sample (x^ = 
4.346, p = .037). Partitioning the affected group by lesion 
location demonstrates that the individuals presenting rib in- 
volvement are not so biased toward males as those presenting 
classic Pott's disease. The comparison for those with rib 
lesions yields a X' of 0.377 (p = .539). The value for the 
more "classic" examples is 3.204 (p < .073). 



168 • Jane E. Buikstra and Sloan Williams 



Summary and conclusions 

Recent years have seen several new and productive ap- 
proaches to issues relating to the tuberculosis-like pathology 
present among prehistoric human remains in the Americas. 
The simulation modeling developed by McGrath suggests 
that a pathogen behaving much like modem M. tuberculosis 
could not have been maintained within certain North Ameri- 
can prehistoric groups. In the face of skeletal evidence docu- 
menting the presence of the disease in west-central Illinois, 
we must consider the possibility that the pathogen responsi- 
ble was not M. tuberculosis and that we are documenting a 
host pathogen relationship not common in recent history. In 
this case, McGrath's model based upon disease experience in 
modem human groups would have been misspecified. 

Clark et al. (1987) have postulated an important role for 
the "environmental mycobacteria" in explaining the expres- 
sion of apparent tubercular disease. While we agree that in 
isolated cases, the possibility that skeletal lesions resulting 
from the atypical mycobacteria may mimic those caused by 
M. tuberculosis, it is unlikely that the environmental patho- 
gens were responsible for many of the tuberculosis-like le- 
sions described for late prehistoric series. Certainly, as at 
Moundville, it is possible that disease prevalence was influ- 
enced by the presence of environmental mycobacteria. Fur- 
ther investigations of geographic distributions for the my- 
cobacteria and prevalence figures for ancient disease may, 
therefore, prove instructive. 

Finally, we have described patteming for a tuberculosis- 
like pathology in a large series of skeletons from southem 
Peru. Although prior studies of Andean remains had de- 
scribed an age-specific lesion pattern different from that re- 
ported in North America, the Estuquina site series shows 
strong similarity to their northern contemporaries. The 
strong sex bias in the sample, however, remains problematic. 

In closing we would like to take issue with Clark et al.'s 
(1987:58) assertion that "from the anthropological perspec- 
tive, differential diagnosis is unproductive, at least when 
adaptation and evolution are the primary foci." We must 
engage in differential diagnosis, if we are to represent fully 
and accurately the health status of prior human groups. Oth- 
erwi.se we risk confusing the degenerative results of occupa- 
tional stress with the products of trauma, the treponematoses 
with fungal infections, the presence of widespread, epidemic 
disease with the impact of environmental pathogens, and the 
impact of nutritional imbalance with the results of infectious 
processes. Without concern for differentiating disease forms, 
we will at best obfuscate and at worst misrepresent the course 
of human history. Differential diagnosis is no more an empty 
exercise than theorizing without considering contradictory 
empirical evidence. The study of human adaptation in the 
past requires scientific methodology, including both theory 
and data-based tests. As illustrated by the current controver- 
sies surrounding prehistoric "tuberculosis" in the Americas, 
differential diagnosis plays a crucial role in this process. 



Acknowledgments 

The research reported here was funded by the National Sci- 
ence Foundation (BNS87- 17590), the Center for Latin Amer- 
ican Studies, and the Lichtstem Fund of the Anthropology 
Department at the University of Chicago. The content and 
organization of the document has benefited immeasurably 
from the criticism of Mary Powell and Lisa Leuschner. 

Appendix. Individuals with tuberculosis-like pathology 
from Estuquina site 

M6-I8I : Sex unknown, 25-30 years. ResorpU\e areas on intemal 
aspect of ribs. 

M6-336a: Male 39+ years. At time of death remodeling was active 
in lumbar region. LI only slightly affected, with resorption on 
inferior and lateral aspects of body. Much of this area does not show 
sclerotic emargination . Superior aspect of L4 has a ca. 5-mm cavita- 
tion with sclerotic emargination that appears to have recently 
"broken through" to surface. Disk spaces in lumbar region and at 
L5-S1 have been crossed by process. Anterior aspect of L2-S1 
bodies also present periosteal proliferation. 

M6-771 : Child 2-3.25 years. Slight amount of light, pinpoint 
cribra orbitalia is observable. Porotic hyperostosis appears on oc- 
cipital, near lambdoid suture. All deciduous teeth show dark stain- 
ing on buccal aspect near CEJ. Linear enamel hypoplasia present in 
all incisors. 

Limb long bones show porosity, especially at metaphyses. as well 
as remodeling in areas of tendon/ligament attachment. Both ilia 
present unusual porosity on external surfaces. Sternum very porous, 
especially the manubrium. 

Ribs show sclerotic raised areas on intemal aspect of bodies of 
right ribs 9-12, esp. 1 1 . It is this pathology that has drawn M6-77 1 
into the affected group, along with periosteal remodeling on exter- 
nal aspects of ilia. Remodeling of limb long bones is subtle, not 
fulminating onion-skin expansion noted in others from the Estu- 
quina sample. 

Well-integrated remodeled diaphyseal bone and dental pigmenta- 
tion suggest long-standing health problems for this individual. 

M6-I002: Male 17- 19 years. 7th thoracic unit shows a multilocular 
resorptive area, without much obvious sclerotic emargination. 

M6-I02la: Female 45 + . Right scapula and humerus have con- 
figuration that could be the result of a tubercular prcK-ess. If so, 
onset occurred before individual was fully (skeletally) mature since 
the disease seems to have caused resorption and dislocation of 
humems head, which is fused to glenoid fossa of scapula. Glenoid 
fossa surrounding this area shows focal lesions ca. 5-7 mm in 
diameter, with sclerotic emargination. 

Spinal column heavily involved. There is an oval cavity on C6, 
1.1 X 0.5 cm in diameter, into which C5 fits. Epiphyseal ring of C6 
has formed a buttressing osteophyte, again suggesting long-term 
pathology. This strut was sufficiently efficient that there was little 
apparent loss of effective body height. 

T3; superior surface of body has collapsed into an intemal lesion, 
which displays sclerotic emargination. 

Zagreb Paleopathology Symp. 1988 



Tuberculosis in the Americas: Current perspectives • 169 



T4 shows a small focal resorption on right side of body, with 
epiphyseal ring gone. Body height loss, leading to scoliosis, appar- 
ent. 

T5/T6: circumferential porosity and remodeling on both bodies. 

T7: erosive circumferential lesions, mostly small (ca. 2-3 mm) 
foci. Slightly larger resorptive areas occur within neural canal, 
extending onto pedicles. This is the only pedicle involvement ob- 
served in M6-102la. 

T8 shows a central lesion with the main opening inferiorly di- 
rected, although a superior perforation also occurs. Multilocular 
sclerotic cmargination. 

T9-T10 fused through bodies only, with disk space gone. Ero- 
sive circumferential remodeling on each body. 

Til: circumferential erosion present with one resorptive focus at 
midline. 

TI2 relatively intact. 

L1-L4 ankylosed kyphosed mass, fused through neural arches. 
Body of L3 entirely gone, with a few residual osteophytes. A lesion 
was observed in bixiy of LI , in addition to circumferential erosion 
under anterior longitudinal ligament. L1-L2 fused through arch 
only, as are L3-L4. L4 has massive erosive area under anterior 
longitudinal ligament. 

L5 fused to sacrum. Extensive zygapophysial arthritis is probably 
a secondary result of disease process. 

M6-1025: 5.5-7.5 months. Main involvement is in right hip. Ero- 
sion of acetabulum with onion-skin proliferation extending over all 
of internal and external surfaces. Right femur shows heavy re- 
modeling in area of greater trochanter that extends to linea aspera. 
Unfortunately, this region is poorly preserved. 

M6-1 183a: Male 35-39 years. L5 and SI are affected. L5 shows 
evidence of an active disease process eroding inferior surface of 
body. Sclerotic reaction clearly present, with bony reactive pro- 
cesses active at time of death. Trabeeulae coarsened. Neural arches, 
i.e., zygapophysis, affected by osteoarthritic change secondary to 
disease. SI presents a complementary lesion pattern. 

M6-1 183b: Male 50+ . Remodeling observed on interhal aspects of 
ribs. Surface well integrated: costal groove obliterated. 

M6-I2I5: 12-15 years. Remodeling evident at sternal ends of ribs. 

M6-I223: 5-7 months. An infant with fiberbone periostitis begin- 
ning to develop on internal aspects of both ilia, r > I. Long bones 
show evidence of periosteal remodeling. Both internal and external 
surfaces of cranial vault are slightly porous. 

M6-1557: Sex unknown, adult. Periostitis observed on internal as- 
pect of ribs. 

M6-l6IOa: Male 45-50 years. Periostitis observed on internal as- 
pect of ribs. 

M6- 1616a: Male 35-45 years. Internal surface of ribs shows evi- 
dence of integrated periosteal reaction. 

M6-2256a: Male 30-40 years. 9th and 10th thoracic elements are 
affected. This may be an ostcomyclitic process since no other vcr 
tebrae are affected, but will include it as a possible example of 
tuberculosis. 

Zagreb Paleopathology Symp. 1988 



T9: much of body destroyed by disease process. Superficial new 
bone formation is present. Only approximately 2/3 of superior sur- 
face is intact, as is right side. Superficial remodeling present on 
external aspect of vertebral body. Sclerotic reaction of trabeeulae 
bone has smoothed interior "surface," although two oval reaction 
area remnants remain. 

TIO: body height maintained on left side. Sclerotic emargination 
of oval lesions evident in body. 

Kyphosis due to complementary destruction of these two ver- 
tebrae could have led to an acute angulation of as much as 30°. 

M6-2279b: Male 20-21 years. L5 (only lumbar vertebra fully ob- 
servable) shows extensive remodeling on superior surface of body 
and multiloculated lesions. Body height reduced. Lesions extend 
into pedicles. Other lumbar fragments suggest no additional units 
affected. 

M6-2297a: Male 27-30 years. Involvement of T9-T1 1 which pres- 
ent multiloculated erosive areas. No loss of vertebral body height, 
no arch involvement. Destructive foci extending across disk space 
apparent at levels of T9-TI0, TIO-Tl I . Sclerotic cmargination of 
resorptive regions is characteristic. 

M6-2330: 1-2 years. Inferior surfaces of centra of two lumbar 
vertebrae present extensive remodeling and multiple small, 
coalesced resorptive areas. In addition, sternal extremity of three 
left ribs present expansive periosteal remodeling. 

M6-3l98a: Male 20-21 years. L5 (only lumbar vertebra fully ob- 
servable) shows extensive remodeling on superior surface of body. 
Multiloculated lesions apparent, and extend into pedicles. Body 
height diminished. Other lumbar fragments suggest no additional 
units affected. 

M6-3205: Male 27-30 years. Periostitis observed in internal aspect 
of ribs. 

M6-3215: Male 25-30 years. Heavily remodeled spinal column 
and lower portion of body. Long bones porous , with some periosteal 
reaction. Weight-bearing joint surfaces somewhat porous. Tarsals in 
general are light in weight, and appear expanded and porous. Meta- 
tarsal bodies show periostitic reaction. Auricular surface of right 
innominate heavily eroded, with some sclerotic emargination. 
Remnants of oval lesions evident. 

Circumferential remodeling evident on T3-TI 1 . T4 shows some 
porosity that may be post mortem. Part of inferior body has col- 
lapsed into internal lesion. Sclerotic emargination is obvious. 

T7: anterior portion of body eroded and absent. 

T8: left side of body eroded and absent. Focal lesions evident, as 
is sclerotic emargination. 

T9: 1.8 X 1 .3 cm resorptive space present on right side of body. 
This feature leads into internal, smaller focal resorption. Body has 
collapsed with little proliferative reaction. 

Ribs: at least three left and five right show expansion on internal 
aspect of neck. Proliferative reaction has added up to 2 mm of new 
bone. Both sclerotic and active fiberbone reaction is evident from 
mid to lower thorax. These bodies are expanded internally such thai 
costal grooves are indistinct. 

M6-324Ha: Female 25-26 years. Evidence of remodeled perio,stitis 
on internal aspect of ribs. 



170 • Jane E. Buikstra and Sloan Williams 



M6-3269a: Sex unknown, adult. 
internal aspect of manubrium. 



Periosteal reaction obvious on 



M6-3299: Male 18- 19 years. Periostitis observed on internal aspect 
of ribs and on anterior surface of L3. 

M6-3644a: Female 25-26 years. Remains were recovered from a 
collar tomb that contained a minimum number of five individuals, 
including three adults. Two adjacent (T9/TI0) lower thoracic ver- 
tebrae exhibit massive resorptive lesions within the bodies. On 
sufx;rior surt'ace of T9, three coalesced large foci arc visible. Body 
height maintained on right side, but destroyed on left. Only anterior 
and right side of TIO body present, showing circumferential bone 
proliferation. Erosive lesions have destroyed interior portion of 
body. Inferior aspect had apparently fused to Tl I (not recovered). 
Right postzygapophysis and inferior surface of a 2d or 3d lumbar 
vertebra from this set of commingled remains also show extensive 
resorption. 

M6-4I65: Male 27-30 years. Solitary lesion apparent on left side of 
L4 body, ca. 2 cm in diameter, that perforates to left side. Modest 
amount of proliferative bone around lesions. Osteophytes extend to 
L3. L3 not affected. 

M6-4176: Male 22-24 years. Right sacroiliac articulation heavily 
eroded by disease process, which is somewhat obscured by post- 
mortem change. A lesion on articular surface has penetrated exter- 
nal surface. Periosteal reaction evident on opposite external face. 
Reaction evident on proximal portion of right femoral diaphysis. 

M6-42l3a: Female 50+ years. Ribs present internal expansion of 
bone well integrated at time of death. No costal groove observable. 

M6-4256: Male 45+ years. TIO-TI 1 affected by erosive process 
that has produced extensive loss of body height on inferior aspect of 
TIO and superior aspect of Tl I. A kyphosis of ca. 30° was pro- 
duced. Sclerotic emargination evident on all lesions. Pedicles af- 
fected on both vertebrae. 

At least five left and two right ribs show periosteal reaction on 
their vertebral aspects, extending across bodies past angles. Costal 
grooves obscured. In that these are lower ribs, the reaction is proba- 
bly related to degenerative process observed in vertebrae. 

M6-4268: Female 22-24 years. Periostitis observed on internal 
aspect of ribs. 

M6-5390: Female 50+ years. This individual shows characteristic 
and extensive skeletal changes. 

Right ilium ankylosed to sacrum. 

Vertebral involvement extensive. Initial focus of disease process 
was In bodies of T10-TI2, with subsequent extension to LI-T9. 
kyphosis (ca. 90°) and ankylosis. Lesions occur adjacent to disks in 
L5 and T9-TI2. L2, T3, T4. T5, and T6 present oval resorptive 
areas posterioriy, adjacent to foramina for basivertebral veins. Cir- 
cumferential resorption occurs in T3-T8 and L3. The most exten- 
sive neural arch involvement Is in L2. with pedicles affected In T4- 
T7, T9-T12, and L3. Transverse processes show pathological re- 
sorptive areas In TS-T?. 



Bones of feet somewhat porous, with notable periostitis on lateral 
aspect of calcancl. There are two sets of fused foot phalanges. 

Most ribs, nine left, eight right, have arthritic articular facets in 
addition to periostitis located on their necks. Most Inferior ribs are 
remodeled externally. 

M6-5428: Male 50+ years. Healed periosteal reaction evident on 
internal aspect of ribs. 

M6-5838a: Female 50+ years. Periostitis on internal surface of rib. 

M6-5859: Male 35+ years. Periostitis noted on Intemal aspects of 
ribs. 

M6-6464: Male 35-39 years. LI and L3 both have resorptive le- 
sions, with anterior surface of L3 and posterior surface of LI being 
affected. Right acetabulum and caput femoris present trabecular 
exposure following premortem cortical resorption. Left scapula 
also has a large channel extended vertically through glenoid fossa. 

M6-82 lOa: Se.x unknown, middle-old adult. Healed periosteal reac- 
tion on Intemal aspect of ribs. 

M6-9334: Male 39-44 years. Small resorptive area on superior 
surface of rib. 

M6-99407b: 2.5-3.0 years. Ribs expanded, as are long bones and 
ilia. Involvement of ribs emphasized. 



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Summary of audience discussion: Several audience members 
expressed concern about drawing conclusions about etiological 
agents for human di.scase on the basis of theoretical mathematical 
models. Some pointed out that disease rates did not always correlate 
with population size, such as the high rate of tuberculosis in the 
small Bedouin groups. It was noted, however, that the author was 
identifying the larger population size with which certain smaller, 
more isolated groups came into contact during their periodic rituals. 



Zagreb Paleopathology Symp. 1988 



Endemic treponematosis and tuberculosis 

in the prehistoric southeastern United States: 

Biological costs of chronic endemic disease 



Mary Lucas Powell 



1 he importance of infectious disease as a selective force in 
human adaptation has been argued eloquently during the past 
quarter century (Alland 1970; Armelagos et al. 1978; 
Buikstra 1981; Buikstra and Cook 1980; Burnet and White 
1972; Cockbum 1973; McNeal 1976; Ortner and Putschar 
1981). Many recent assessments of health in prehistoric pop- 
ulations have treated only in general terms the observed prev- 
alence of nonspecific periostitis, osteitis, and osteomyelitis, 
with little or no consideration of specific infectious diseases. 
The most commonly reported nonspecific lesion, periostitis, 
may represent illness caused by endogenous bacterial and 
viral infections, certain endemic (and more rarely, epidemic) 
infectious diseases, nutritional disorders, trauma, or a vari- 
ety of congenital syndromes (Greenfield 1980; Jaffe 1972). 
Its mere presence in an individual or a population reported 
without an epidemiological context is of minor significance 
in evaluation of the biological costs of infectious disease 
experience. 

Differential diagnosis of specific infectious diseases re- 
quires familiarity with the pathogenesis and epidemiology of 
the diseases in question. Certain infectious diseases such as 
treponematosis and tuberculosis produce both pathog- 
nomonic skeletal pathology (e.g., caries sicca in the former, 
extensive vertebral destruction in the latter) and nonspecific 
response. Ortner and Putschar (1981:105) note that "infec- 
tious conditions affecting the skeleton tend to be subacute, 
chronic diseases and may not be the immediate cause of 
death." Because bone lesions typically occur relatively late 
in the progress of disease subsequent to considerable soft 
tissue involvement, their presence is indicative of relatively 
long-term immune response. Some chronic diseases typ- 
ically produce abundant skeletal morbidity yet rarely result in 
death, because of the nature of their pathophysiological 
effects, while others may produce high mortality but few 
cases of skeletal involvement (Hackett 1951; Robbins and 
Cotran 1980). This paperoutlinesbriefiy the different biolog- 
ical costs of two chronic infectious di.seascs with distinctive- 
ly different patterns of skeletal involvement and mortal im- 

iagrtb Paleopathology Symp. 1988 



pact, endemic treponematosis and tuberculosis, that have 
been recently identified in skeletal samples from late 
prehistoric American Indian populations in Alabama and 
Georgia. 

Endemic treponematosis and tuberculosis 

Yaws, endemic syphilis, and venereal syphilis are considered 
to be closely related disease entities because of the similarity 
of their causal organisms and the morphology of their lesions 
of skin and bone (Grin 1953; Hackett 1976; Hudson 1958; 
Turner and Hollander 1957). As regards levels of morbidity 
and mortality, however, the first two are radically different 
from their more dangerous relative, being both more widely 
prevalent and more benign because of their mode of trans- 
mission and their pathophysiological effects. They are typ- 
ically contracted in early childhood through direct contact 
with infectious skin lesions rather than through venereal 
transmission. Prevalence levels in endemic regions approach 
100%, and lesions occur in approximately 50% to 75% of 
late secondary and tertiary cases, resulting from hyper- 
allergic response to superinfection by the sensitized hosts 
(Hackett 1951). Both congenital transmission and invasion 
of vital organ systems are rare, in contrast to the well- 
documented effects of venereal syphilis (Grin 1956; Murray 
et al. 1956). These diseases do not noticeably dampen fertil- 
ity, and exert a negligible impact upon mortality except indi- 
rectly through secondary bacterial or mycotic infection of 
skin lesions. 

In his comprehensive study of endemic yaws in Uganda 
( I95I ), C.J. Hackett sought to document the complete range 
of bone lesions observed radiographically in patients diag- 
nosed by serological analysis. He noted in his introduction, 
"It is not the differential diagnosis of the changes present in 
one patient, but of those ... in a whole population that is 
being considered." Hackett found that while some patients 
displayed "classic" bone lesions characteristic of late second- 
ary and tertiary yaws (sabre shins, polydactylitis, and os- 

173 



174 • Mary Lucas Powell 



Table 1. Tuberculosis and endemic treponematosis: comparison of morbid and mortal effects 



Pathogen 

Mode of infection 
Modal age at exposure 
Modal age at onset 

of disease 
Duration of infectious 

state of patient 



Initial lesions 
Subsequent lesions 
Prevalence of disease 

in endemic contexts 
Prevalence of skeletal 

involvement 
Predominant skeletal 

response 
Skeletal regions 

typically affected 



Potential for mortal 
effect 



Tuberculosis 



Treponematosis 



EPIDEMIOLOGY 

Mycobacterium 

tuberculosis 
Respiration, ingestion 
Childhood 
Late adolescence, 

early adulthood 
Decades (with 

latent periods) 



Treponema pallidum, 
T. pertenue 
Skin lesions 
Childhood 
Childhood 

5-10 years 



PATHOLOGY 

Lungs, hilar lymph nodes 
Any organ system 
10-50% of exposed 
individuals 
3 - 15% of cases 

Major: osteolytic 
Minor: osteoblastic 
Spinal column, 

hip and knee joints, 

ribs, sternum 

Moderate to high 



Mucocutaneous tissues 
Mucocutaneous tissue, bone 
Virtually 100% of exposed 
individuals 
50-75% of cases 

Major: osteoblastic 
Minor: osteolytic 
Tibia, fibula, humerus, 

radius, ulna, clavicle, 

cranial vault, 

nasopalatal region 
Low 



Sources: Hackett 1951, Hoeprich 1977, Hudson 1958, Kelley and Micozzi 1984, Myers 1951, 
Ortner and Putschar 1981, Robbins and Cotran 1980 



teolytic lesions of the external cranial vault and nasopalatal 
region), many more exhibited minor nonspecific bone reac- 
tions (periostitis of long bone shafts, particularly the tibia, 
fibula, ulna, radius and clavicle). Subsequent radiographic 
examination of these patients indicated long-term persistence 
of bone changes after the disappearance of the clinical symp- 
toms. 

Commenting upon the high level of moderate skeletal mor- 
bidity without associated mortality, Hackett concluded that 
"it is improbable that septic infection of the bones is responsi- 
ble for the changes seen. Untreated septic infection of the 
extent necessary to produce the wide spread changes seen in 
some cases would be accompanied by grave general symp- 
toms and high mortality; whereas the patients showing these 
bone lesions were not severely ill. although they suffered 
considerable discomfort" ( 1 95 1 : 1 3). Studies of yaws in other 
populations (Grin 1956) and of endemic syphilis in Bosnia 
(Grin 1953) and in southern Africa (Murray et al. 1956) 
present similar pictures of the biological costs of these dis- 
eases. 

Zagreb Paleopathology Symp. 1988 



Tuberculosis is a chronic infectious disease caused by the 
gram-negative Mycobacterium tuberculosis. Clinical studies 
indicate that in endemic contexts, most people are infected in 
infancy or childhood, but more than half of the exposed but 
otherwise healthy individuals may never develop clinical dis- 
ease (Myers 195 1 ). Individuals with poor immune response 
may develop primary lesions within the lungs and hilar 
lymph nodes. If death does not ensue during the primary 
infection, the invading pathogens may be encapsulated by 
calcified tissue. This response halts immediate progression 
of the disease, but the organisms remain viable for decades 
(Robbins and Cotran 1980). Localized foci may rupture and 
spread mycobactena via direct or hematogenous dissemina- 
tion throughout the body, affecting all types of tissue includ- 
ing bone. Reinfection from active cases or reactivation of 
latent foci because of severe systemic stress may produce 
acute symptoms later in life (Hoeprich 1977). 

In chronic tuberculosis overstimulation of immune re- 
sponses in sensitized tissues may result in such proliferation 
of granulomatous tissue within the lungs that pulmonary 



Treponematosis and tuberculosis in tiie prehistoric southeastern United States • 175 



function is compromised and death follows. Tuberculosis 
was a major cause of death in children, adolescents and 
young adults before the development of effective surgical 
and antibiotic therapy and was responsible for 260 deaths per 
100,000 residents in Germany in 1892 (Ortner and Putschar 
1 98 1 : 1 42 ). Mortality from tuberculosis is particularly high in 
populations under severe stress from malnutrition, over- 
crowded and unsanitary living conditions, other diseases, 
and psychosocial stress (Hrdlicka 1909; Hoeprich 1977; My- 
ers 195 1 ). Under more healthful conditions, successful repair 
of tissue destruction permits extended survival of the host, an 
outcome incidentally in the pathogen's favor as it promotes 
subsequent infection of other hosts. 

Table 1 summarizes the contrasting morbid and mortal 
effects of endemic treponematosis and tuberculosis. These 
differing patterns have important implications for paleo- 
pathological studies of the two diseases, for the following 
reasons. Tuberculosis is less "visible" than endemic trep- 
onematosis in skeletal series. In older museum collections, 
spinal elements tend to be less well represented than long 
bones because vertebrae are more prone to postmortem de- 
struction and because in many field situations they were less 
systematically collected. In the Moundville series, for exam- 
ple, fewer than 407c of the individuals were represented by 
thoracic and/or lumbar vertebrae, the most common sites of 
tubercular bone lesions. By contrast, more than 70% were 
represented by the postcranial bones most characteristically 
affected by treponemal infection. 

The nature of the lesions produced by the different diseases 
also plays a role in affecting favorably or unfavorably the 
chances for postmortem preservation. The osteolytic lesions 
characteristic of tuberculosis destroy bone tissue and weaken 
the fabric of affected skeletal elements. The osteoblastic le- 
sions characteristic of endemic treponematosis produce addi- 
tional bone, thickening the cortex of affected long bones and 
rendering them more resistant to dissolution. 

Materials and methods 

The first population sample discussed in this paper was exca- 
vated from the prehistoric American Indian community of 
Moundville located on the Black Warrior River some 13 
miles southeast of Tuscaloosa in west central Alabama. It 
represents the Mississippian occupation of the site, which 
lasted from A. D. 1050 to 1550. By the mid- 14th century, an 
estimated 3000 individuals were concentrated within the pro- 
tective palisade and in small "suburban" clusters located 
nearby. The subtropical climate and the easily cultivated, 
fertile soils encouraged the development of a sophisticated 
subsistence regimen combining maize, squash, and beans 
with a wide variety of plentiful wild plant foods, game, and 
fish (Peebles 1978). 

More than 1500 burials were excavated at Moundville 
between 1929 and 1941 by the Alabama State Museum of 
Natural History, and are presently curated at the Laboratory 

Zagreb Paleopathology Symp. 1988 



for Human Osteology at the University of Alabama in 
Tuscaloosa. From this large series, 564 skeletal individuals 
were selected on the basis of preservation and archeological 
provenience for investigation of the social and biological 
dimensions of health (Powell 1988). 

The second population sample represents a late prehistoric 
community at the Irene Mound site, located near the mouth 
of the Savannah River on the Atlantic coast. This occupation 
was contemporaneous with Moundville, spanning three cen- 
turies (a. D. 1 1 10- 1400) during the Savannah and early Irene 
phases of the local Mississippian cultural tradition. Sub- 
sistence and other aspects of life in this smaller community 
were similar to those noted for Moundville. Continuous ar- 
cheological excavations at the site from 1939 to 1940 sup- 
ported by federal relief funds recovered 265 skeletal individ- 
uals, presently curated at the National Museum of Natural 
History, Smithsonian Institution, in Washington. D.C. The 
data reported here were collected as part of a general assess- 
ment of health at Irene Mound (Powell 1990). 

For each series, all available bones were examined for 
macroscopic evidence of skeletal pathology. Observed le- 
sions were classified as osteoblastic or osteolytic in morphol- 
ogy, as active or quiescent at the time of death, and according 
to their extent of involvement. The differential diagnoses of 
treponematosis and tuberculosis were based on identification 
of pathognomonic lesions and comparisons of the patterns of 
associated nonspecific skeletal pathology (Figure 1). 




Venereal 
Syphilis 



Endemic Syphilis Yaws 



Ivloundville 
Treponematosis 



Figure 1. Distribution of skeletal lesions in four treponemal 
syndromes. Solid shaded areas are those most frequently 
affected; hatched areas are less often involved. Figures show- 
ing syphilis and yaws after Steinbock 1976. 



176 • Mary Lucas Powell 




Figure 2. Irene Mound, NMNH 385528, 
treponematosis, sabre shins (shown with non- 
pathological tibia, center, for comparison). 




Figure 3. Moundville, tibia. 



Results 



A diagnosis of endemic treponematosis was initially sug- 
gested in both series by the frequent appearance of localized 
or extensive periostitis on the shafts of the tibia, fibula, ra- 
dius and ulna. The thickness and degree of remodeling of this 
new bone suggested the recurrent episodes of periosteal in- 
flammation described by Hackett (195 i) during the late sec- 
ondary and tertiary stages of yaws. Many tibiae display areas 
of localized apposition along the anterior crest, a region sub- 
ject to the frequent minor trauma noted by Hackett as an 
exacerbating factor in soft tissue lesion formation. Others 
show more severe extensive pathological involvement, illus- 
trated by cases from Irene Mound (Figure 2) and Moundville 
(Figure 3) that resemble the deformity known in modem 
treponematosis as "sabre shins." 




Md 1394 
Figure 4. Moundville, cranial lesions. 







-. 






f* 


-V. 


./^-.. 

«■ 






L. 1 1 1 


5 
1 1 


; Md 1381 

i 


C ent ime t ers 





Figure 5. Moundville, cranial lesion in frontal. 



Other lesions suggestive of late-stage treponemal disease 
appear as small, circular depressions on the outer cranial 
vault, seen here in an adult case from Moundville (Figure 4). 
The gummatous ulcers that often develop in yaws and en- 
demic syphilis frequently infect bone lying close beneath the 
skin. Their particular pattern of tissue destruction and heal- 
ing results in the pathognomonic osteolytic lesions known as 
"caries sicca" (Hackett 1976). The cranial lesions seen in 
these series are neither large nor extensive, and show con- 
siderable remodeling before death. The single exception is a 
large, penetrating, frontal lesion (Figure 5) from a young 
Moundville woman who probably died from superinfection. 
Posterior vault lesions (Figure 6) often show more clearly 
than frontal lesions the characteristic stellate configuration of 
the healed scar. 

The mucocutaneous and osseous tissues of the nasal and 
oral cavities are also common sites of treponemal pathology. 
Osteolytic lesions penetrated the palate and maxilla of a 

Zagreb Paleopathology Symp. 1988 



Treponematosis and tuberculosis in the prehistoric southeastern United States • 177 





Figure 6. Moundvilie. posterior cranial vault, stellate le- 
sions. 



Figure 7. Irene Mound, NMNH 385540, treponematosis, 
right nasal margin remodeling. 



young adult female from Irene Mound (Figure 7), who also 
displays remodeled frontal lesions. The right border of her 
nasal aperture shows extensive remodeling. Destruction of 
facial structures of this sort is known as "gangosa," a Spanish 
word referring to the harsh nasal quality of the victim's voice 
(Hudson 1958). Because of their pre-Columbian prove- 
nience, no historical descriptions of the Moundvilie or Irene 
Mound populations exist. However, in 1709 the Englishman 
John Lawson described ailments that resemble endemic trep- 
onematosis among the Santee Indians some 200 miles to the 
north of Irene Mound. He wrote, ". . . they have a sort of 
Rheumatism or Burning of the Limbs, which tortures them 
grievously, at which times their legs are so hot, that they 
employ the young People continually to pour water down 
them" (1709:223). Lawson also noted "another Distemper, 
which is, in some respects, like the Pox, but is attended with 
no Gonorrhea. This not seldom bereaves them of their 
Nose." (1709:223). The Santee made a clear distinction be- 
tween pre-Contact and post-Contact diseases, leading Law- 
son to comment "... the Natives of America have for many 
Ages (by their own Confession) been afflicted with a Dis- 
temper much like the Lues Venerea which hath all the Symp- 
tions of the Pox, being different in this only: for 1 never could 
learn, that this Country-Distemper, or Yawes, is begun or 
continued with a Gonorrhea. ... I have known mercurial 
Unguents and remedies work a Cure, following the same 
methods as in the Pox" (1709:18). 

The "Rheumatism" and "nocturnal pains in the limbs" 
described to Lawson by the Santee correspond well to the 
episodes of ostalgia (deep bone pain) that afflict late second- 
ary and tertiary cases of yaws and endemic syphilis. The 
ulceration and loss of nasal structures, the ab.sence of urethral 
discharge ("gonorrhea"), the responsiveness of the skin le- 
sions to "mercurial Unguents and Remedies," and the essen- 
tially self-limiting nature of the disease are also prominent 
characteristics of endemic treponematoses. 

Zagreb Paleopalhology Symp. 1988 



In both series, the demographic profiles of individuals 
displaying skeletal pathology diagnostic or suggestive of en- 
demic treponemal disease closely matched the demographic 
profiles of the series as a whole. Skeletal evidence of the 
disease was age-accumulative: older adults were more likely 
to bear lesions than were younger adults, adolescents, or 
children. The great majority of the observed lesions were 
well remodeled, indicating that the disease was not active 
around the time of death. 

Lawson commented that the Santee "are wholly Strangers 
to . . . the Phthisick," a term referring to pulmonary tuber- 
culosis (Jaffe 1972:955). Although it may have been absent 
in that population, tuberculosis is evidenced by a variety of 
skeletal lesions at Moundvilie and at Irene Mound. Of the ten 
individuals from Moundvilie with bone lesions diagnostic of 
tuberculosis, only one displays "classic" vertebral destruc- 
tion. This young man died in his late twenties, a decade short 
of the average adult male age at death. Virtually his entire 
spine from T3 downward to his sacrum shows pathological 
involvement (Figure 8). The bodies of six thoracic vertebrae 
have been destroyed, producing the anterior kyphosis char- 
acteristic of spinal tuberculosis or Pott's disease. Numerous 
large round osteolytic lesions with smooth margins appear in 
the bodies of several lower thoracic and lumbar vertebrae. As 
compensation for the loss of bone mass, the remaining por- 
tions of several vertebrae have fused to provide support for 
the thorax. Ribs 6 through 10 on both sides display small 
shallow osteolytic lesions and poorly remodeled periostitis 
on their pleural aspects. Their necks and heads are considera- 
bly distorted, with the same combination of destructive and 
proliferative reaction. No other postcranial tuberculous le- 
sions were noted, and the skull is unfortunately absent. The 
extensive remodeling evident in all areas of pathological in- 
volvement indicates survival for some considerable length of 
time despite severe deformity, as has been abundantly dcKU- 
mented in modem clinical cases (Myers 1 95 1). 



178 • Mary Lucas Powell 








Figure 8. Moundville, spinal tuberculosis. 




Figure 9. Irene Mound, NMNH 385562, lumbar vertebrae, 
TB lesions. 



Two mature women from Moundville each bore osteolytic 
lesions on a single lumbar vertebrae, but such isolated de- 
struction suggests a diagnosis of blastomycosis rather than 
tuberculosis (Chick 1 97 1 ). No cases with tuberculous lesions 
of the hip, knee, or cranium were observed. However, seven 
adults and two subadults displayed rib lesions closely match- 
ing those described from clinical cases in the Hamann-Todd 
collection by Kelley and Micozzi (1984) as characteristic of 
chronic pulmonary tuberculosis. The two subadults (ages 
birth to 6 months and 7 to 8 years) display extensive, diffuse, 
unremodeled periostitis on the pleural aspects of multiple 
right and left ribs. The seven adults were evenly distributed 
through the third, fourth, and fifth decades of life, and all 
displayed lesions at least partially remodeled at death. Wom- 
en and men were equally represented. This age and sex dis- 
tribution of adult cases matches that reported in the Hamann- 
Todd study. 

In the Irene Mound .series, three cases bear osteolytic le- 
sions in thoracic or lumbar vertebrae suggestive of spinal 
tuberculosis. L2 through L5 of a young woman (Figure 9) 
display extensive shallow lesions on the paradiscal surfaces. 
T3 and T4 of a second young woman bear deep centrally 
located osteolytic lesions , and L2 through L5 of a young man 
exhibit widespread circumferential lesions. One older wom- 
an displayed extensive destruction of her left sacroiliac au- 
ricular surface with minimal remodeling (Figure 10). Two 
adults displayed periostitis on the pleural aspect of the 
.scapula, and the pleural aspect of the sternum was also sim- 
ilarly affected in one case. 

As in the Moundville series, the most abundant extraver- 
tebral tuberculous lesions were those alTccting the pleural 
aspects of the ribs. These lesions appeared in 8 of the 10 



cases. In one case focal osteolytic lesions were surrounded 
by osteoblastic response. Seven of the 8 displayed localized 
or diffuse periostitis, illustrated here by the most extreme 
case (Figure 1 1), the young female adult with multiple lum- 
bar paradiscal lesions. 

The mean age at death of the 10 Irene Mound cases with 
tuberculous vertebral, pelvic, and rib lesions was 29.5 years, 
five years below the modal sample age of 34.9 years. One 
young adolescent, one older adolescent, and four adults aged 
20 to 24.9 years constituted the younger set of cases. Ap- 
proximately 15 years separated the oldest of these cases from 
the youngest of the four remaining cases, all in their early to 
late 40s. Female prevalence is double that for males, in con- 
trast to the equal representation of the sexes at Moundville. 

Conclusions 

Analyses of archeological data on subsistence and skeletal 
indicators of nutritional quality at Moundville and Irene 
Mound suggest that both populations enjoyed diets adequate 
to promote vigorous immune response to infectious disease. 
The rank-stratified social organization of the Moundville 
chiefdom may have created certain dietary differences be- 
tween elite and non-elite segments of the population, but a 
broad range examination of the social dimensions of health 
and disease at the paramount site revealed no significant 
differences in dental disease or skeletal pathology (Powell 
1988). The nature and degree of social dilTerentiation at Irene 
Mound have not yet been delineated, but significant rank- 
determined, dietary inequalities seem improbable (D.G. An- 
derson, pers. comm. 1987). Good nutrition is a less critical 
factor in resistance to endemic treponematosis than in re- 

Za^reh Paleopalholo^y Symp. t9SH 



Treponematosis and tuberculosis in the prehistoric southeastern United States • 179 





Figure 10. Irene Mound. NMNH 385411, SI joint lesion, 
TB. 



Figure 1 1 . Irene Mound, NMNH 355562, ribs, pleural peri- 
ostitis. 



sistance to tuberculosis (Hackett 1951; Myers 1951), but its 
importance to nonspecific mechanisms safeguarding health 
(e.g. phagocyte production) should not be forgotten. 

The human remains excavated from these sites some fifty 
years ago and carefully curated as part of systematic museum 
collections in Alabama and Washington, D.C., provide con- 
vincing diagnostic evidence of the presence of two chronic 
endemic infectious diseases. Analysis of the patterns of the 
associated bone lesions indicates to some degree the breadth 
of their prevalence within the populations, respecting neither 
demographic parameters nor exalted social rank. But the 
skeletal record alone cannot convey the full extent of the 
biological costs of these insidious and persistent forms of 
illness, the toll levied upon each successive generation in 
terms of death, discomfort, deformity, decreased energy, and 
general debilitation of resistance to other stresses. Each dis- 
ease followed its own distinctive trajectory from childhood 
infection through subsequent episodes of illness throughout 
adult life, the one more blatantly disfiguring and the other 
more subtly lethal . The presence of each made the presence 
of the other a greater burden to the unfortunate individuals 
who were doubly afflicted and to the populations in general. 
Endemic treponematosis was no doubt regarded as one of 
life's regular nuisances, while tuberculosis was a rarer but far 
more serious matter. 

An eminent paleopathologist of the author's acquaintance 
continually adjures his students to "remember that a dog may 
have both ticks and fleas," and that differential diagnosis 
should always be sensitive to the possibility of multiple 
pathological conditions simultaneously affecting an individ- 
ual. To apply this same analogy again in a somewhat different 
manner, the skeletal lesions of endemic treponematosis and 
tuberculosis may be likened to the parasites visible on a dog's 
body. Their simple presence in terms of the amount of blood 

Zagreb Paleopathology Symp. 1988 



consumed, the burden of their collective weight, and the 
minor irritation of their bites does not reflect directly the 
magnitude of their potential impact upon the dog's health. 
Hidden within them may be agents that produce serious ill- 
ness or death, depending upon the circumstances surround- 
ing host and parasites. 

In similar fashion, the degree of skeletal pathology ob- 
served does not equal directly the biological costs of the 
diseases in question, either in terms of numbers of individu- 
als who were ill or the range of possible symptoms. Clinical 
studies identify numerous cases that would be invisible in the 
archeological record. What we actually see in the bones is not 
the entirety of disease that did exist, but the evidence alerts us 
to the presence of diseases whose true costs may be inferred 
from the modem epidemiological and clinical literature. 

In the face of growing political pressure for reburial of 
human skeletal remains in the United States and elsewhere, 
paleopathologists should feel a particular obligation to bring 
to bear our most sophisticated theoretical and methodologi- 
cal capabilities to investigations of the dimensions of health 
in the prehistoric past. Differential diagnosis provides a pow- 
erful tool for conducting such analyses, and to ignore its full 
potential is to deliberately limit the contributions of our re- 
search. 

Acknowledgments 

This paper is the result of numerous discussions with Donald 
J. Ortner, my advi.sor during a Postdoctoral Fellowship at the 
Smithsonian Institution, about the problems and potential of 
interpretation of skeletal disease. 1 have benefited greatly 
from his sophisticated insights into critical issues, and he is 
coauthor in fact, if not in name. Misinterpretations of the 
data, however, are solely my own. 



180 • Mary Lucas Powell 



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Buikstra. J.E., ed. 1981. Prehistoric Tuberculosis in the Americas. 
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Buikstra, J.E., and D.C. Cook. 1980. Paleopathology: An Ameri- 
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Burnet, Sir M., and D.O. White. 1972. Natural History of Infec- 
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Chick. E.W. 1971. North American Blastomycosis. InR.D. Baker, 
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Cockbum, A. 1973. Infectious Di-ieases. Their Evolution and 
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Grin, G.I. 1953. Epidemiology and Control of Endemic Syphilis: 
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Hackett, C.J. 1 95 1. Bone Lesions of Yaws in Uganda. Oxford: 
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Hudson, E.H. 1958. Non-Venereal Syphilis, a Sociological and 
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thropology. 65:381-386. 

Lawson, J. 1709. A New Voyage to Carolina. London. 

McNeill, W.H. 1976. Plagues and Peoples. New York: Anchor 
Press. 



Murray, J.F. , A.M. Merriweather, and M.L. Freedman. 1956. En- 
demic Syphilis in the Bakwena Reserve of the Bechuanaland 
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Myers, J. A. 1951. Tuberculosis among Children and Adults. 3d 
edition. Springfield, III.: Charles C Thomas. 

Ortner, D.J., and W.G.J. Putschar. 1981. Identification of Patho- 
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Contributions to Anthropology. 28. Washington, D.C: Smithso- 
nian Institution Press. 

Peebles, C.H. 1978. Determinants of Settlement Size and Location 
in the Moundvillc Phase. In B.D. Smith, ed., Mississippian Set- 
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Powell, M.L. 19&S. Status and Health in Prehistory: A Case Study 
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Institution Press. 

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Robbins, S.L., and R.S. Cotran. 1980. Pathologic Basis of Dis- 
ease. 2d edition. Philadelphia: W.B. Saunders. 

Steinbock, R.T. 1976. Paleopathological Diagnosis and Interpre- 
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Summary of audience discussion: The absence of skull involve- 
ment by tuberculosis in this study is consistent with the paucity of 
reported cases both in ancient and in modem populations. Prior to 
the availability of effective chemotherapy, tuberculous meningitis 
certainly was not rare , and the primarily cortical response which one 
would expect ought to be easily separable from the "caries sicca" 
lesion characteristic of cranial treponematosis. It is conceivable 
tuberculous periostitis is present more frequently than reported but 
overlooked because the lesions may be small, of nonspecific struc- 
ture and difficult to see in an intact skull because of their endocranial 
position. The rapid course of tuberculous meningitis in modem 
populations also probably provides insufficient time for develop- 
ment of the osseous reaction. Since a slower course would imply the 
development of greater resistance to the tubercle bacillus, it is un- 
likely that its course was any slower in antiquity. 



Zagrffe Paleopathology Symp. 1988 



Vertebral tuberculosis in ancient 
Egypt and Nubia 

Eugen Strouhal 



It has become a widely accepted view that diagnosis of 
tuberculosis from archeologically excavated human skeletal 
remains is not easy, but that a reasonably reliable prediction 
can be made if the spine is involved (Haneveld 1980:2). 
Vertebral tuberculosis (spondylitis tuberculotica) was first 
described by Sir Percival Pott, a surgeon at St. Bar- 
tholomew's Hospital in London, in 1779 (Pott 1790) and 
named malum Potti in honor of him. It deserves to be studied 
by modem paleopathologists also 200 years later. Its patho- 
logical anatomy is usually very characteristic, making it pos- 
sible to distinguish it from other spinal diseases. 

While modem clinical reports indicate that skeletal tuber- 
culosis as a rule occurs as a complication secondary to either 
pulmonary or intestinal tuberculosis in about 1% of such 
patients, its incidence was considerably higher during the 
preantibiotic era: between 5 and 7% (Steinbock 1976:175; 
Zimmerman and Kelley 1982:103). In the same period the 
spine was involved in 25-50% of skeletal tuberculosis cases 
(Steinbock 1976:176). This means that cases of skeletal tu- 
berculosis represent about 1-3.5% of the total number of 
people who were infected by tuberculosis. 

It is encouraging that the acid-fast bacterium Mycobac- 
terium tuherculosis (bacillus Kochi) was recently demon- 
strated in a Peruvian mummified child of the seventh century 
A.D. Nasca culture (Allison et al. 1973) as well as in the 
vertebrae and pulmonary blood of an Egyptian mummified 
child from Thebes West, dated 1000-400 years B.C. (Zim- 
merman 1977,1979). Nevertheless, bacteriological tech- 
niques can be used only exceptionally in excavated material 
and the agent of the disease is not always preserved in it. For 
current studies on the incidence of tuberculosis in ancient 
[xjpulations, however, macroscopic and radiological diag- 
nosis of cases of vertebral tuberculosis may still be used as 
convenient and technically simple methods. The presence of 
vertebral tuberculosis has to be considered at the same time 
as evidence for the presence of other tuberculotic forms, such 
as pulmonary, intestinal or glandular, without, however, re- 
vealing their specitlc frequencies (Grmek 1983:265). 

Zagreb Paleopathology Symp I9HH 



Moreover, the description of each newly detected case 
adds some new knowledge to the morphology, extent, and 
course of the disease. This applies to two cases recently 
found in a Middle Kingdom burial in Egypt (case no. 1 ) and 
in a Christian period cemetery in Nubia (case no. 2). They are 
of interest because of their considerable extent and contrast- 
ing developmental phases, pointing to different social im- 
plications. 

Case number 1 

ARCHEOLOGICAL BACKGROUND 

An isolated secondary burial of Middle Kingdom dating was 
found in the 5th dynasty Pyramid Temple of King Raneferef 
at the royal cemetery at Abusir by the mission of the Czecho- 
slovak Institute of Egyptology, Charles University, Prague, 
in 1984. The burial of a male called Khuyankh (Hwy'nh) 
(900/1/84) was placed at the bottom of a rectangular shaft 
excavated in the northern half of room AA-Ec, situated in the 
NE comer of the hut-nemet section of the temple. The lower 
part of the shaft was lined with sun-dried bricks delimiting 
the burial chamber, oriented with its longer axis roughly N-S . 
As no traces of roofing were detected, it seems probable that 
after insertion of the cotTins the shaft was simply filled up 
with sand. 

The dead individual was provided with two coffins. The 
external, box-shaped one was decorated on its outer surface 
by inscriptions, and on its interior sides by further in.scrip- 
tions, coflfin texts, and pictures of offerings. The intemal, 
anthropoid coffin was lying on its left side inside the external 
coffin with the head end to the north. The skeleton, 155 cm 
long, was in an extended position at the bottom of the inner 
coffin with the skull tumed with its face down. 

In the inner coffin two faience beads and the head of a 
wooden stick were found. South of the foot end of the outer 
coffin a low chest was placed, divided by two boards into 
four compartments with remnants of organic matter and 

181 



182 • Eugen Strouhal 



wrappings on their bottom. A large, globular storage vessel 
stood in the NE comer of the burial chamber. 



EMBALMING METHOD 

Several black spots could be observed on the skull. Bones of 
the lower extremities (except the missing femora) were 
stained with a dark, almost violet color. Both are traces of 
resin used to smear the wrappings during embalming. Some 
textile fragments with pieces of stiffened resin were found 
among the bones and fragments of wood of the inner coffin. 
Remnants of dried brain were still present in the cerebral 
cavity. The nasal skeleton was found intact. Both these find- 
ings attest that brain removal was not performed, being re- 
served only for persons of royal or high official rank during 
the Middle Kingdom times (Strouhal 1986:145). 



AGE 

Cranial sutures showed a progressive state of obliteration 
(C3, S2 -(- 3, LI + 2). The complete dentition (with only 
crowns of right upper C and left upper I 1 and 2 broken off) 
was considerably abraded, ranging from points of exposed 
dentine on lower M3 to complete removal of the crowns on 
upper left C and upper right premolars, but without pulp 
exposure. A caries lesion was present on the left lower M2, 
destroying the distal half of the crown and, through involve- 
ment of the pulp, causing a great, longitudinally oriented 
oval cyst opening on the outer aspect of the alveolar process 
(13 X 7 mm, depth 7 mm). Resorption of the alveolar process 
was of medium degree according to the scale of Brothwell 
(1963:150). Considerable deposits of dental calculus were 
accumulated on the upper left molars and on all lower premo- 
lars both buccally and lingually, and on the lower molars 
lingually. Medium large deposits were present on the upper 
right molars lingually (according to the scale of Brothwell). 

All epiphyseal and apophyseal fissures of the postcranial 
skeleton were completely fused. Pubic symphysis relief re- 
sembled phase 8 of Todd (1920) pointing to the range of 39- 
44 years. No synostosis of the sternal parts occurred. Only 
beginnings of lipping on the left humeral head and a rugged 
surface of the tubercula minora could be observed. The 
femora were missing. Slight osteophytic outgrowths were 
present on the patellae, and some of medium size on the 
calcanei. No arthritic changes were apparent in any joint. 
The grade of vertebral osteophytosis in sections not directly 
involved in the pathological changes to be described (CI -7, 
T 1 -8 , L2-5 , S 1 ) was mostly of medium degree (osteophytes 
more than 3 mm long but not bridging) or slight (osteophytes 
less than 3 mm). Spondylarthrosis could be detected in joints 
T6-7 and T7-8 and osteochondrosis of intervertebral discs 
between C5-6 and C6-7, both probably related to the main 
pathology of the spine. 

According to the described features the individual died 
between 40 and 50 years of age. 



SEX 

In spite of only a slightly developed glabella (Broca 2) and 
supraorbital arches (Eickstedt 2) as well as of nasofrontal 
transition on a medium curved arch, most other secondary 
sexual features pointed to the male sex. There was a slightly 
oblique forehead, a medium protuberantia occipitalis externa 
(Broca 2), a medium thick and long mastoid process with a 
deep incisura mastoidea, a medium thick upper orbital mar- 
gin, slightly to medium developed marginal process, a well- 
developed muscular relief of the nuchal and mandibular re- 
gions, a slightly averted mandibular angle, and a broad 
square chin. In addition moderately developed apophyses of 
the pelvis, a medium deep and large ischiatic notch, absence 
of a preauricular sulcus, a big oval foramen obturatum, a 
sagittally narrow pelvic inlet, an outstanding pubic tubercle, 
a flaring lower aspect of the pubic bone, an acute subpubic 
angle (50°), and a low ischio-pubic index (left 65.0, right 
61.3, according to Thieme and Schull 1957:269) all indicate 
the male sex unequivocally. 

GENERAL PHYSICAL FEATURES 

The body build was moderately robust, with musculature 
developed to a medium degree on the lower limbs and 
slightly less developed musculature on the upper limbs. Sta- 
ture was reconstructed according to the tables of Trotter and 
Gleser ( 1 952) for American Negroes, which were found to fit 
better to proportions of the Nubians (Strouhal and Jungwirth 
1984:119-122) as well as Egyptians (Robins 1983:17-20), 
and appeared high (171 .4 cm). 

SPINAL PATHOLOGY 

The vertebral column viewed from the sides was strongly 
bent in the lower thoracic third (Figures 1 ,2). The bodies of 
five vertebrae — T9 to LI — were completely merged and 
their neural arches, intervertebral joints, and ventral portions 
of the interspinous ligaments (the last except TlO-1 1, Fig- 
ures 3-5) were also fused. While the body of LI retained its 
individual shape, bodies of the last four thoracic vertebrae 
had almost disappeared and their remnants joined into an 
uniform, wedge-shaped formation (anterior height 2 mm, 
posterior height 36 mm) merging with the wedge-shaped 
body of LI (anterior height 7 mm, posterior height 20 mm). 
The radiogram (Figure 6) revealed a regular, strain- 
conditioned trabecular structure without remnants of residual 
cavities or intervertebral spaces. The right side of the forma- 
tion was covered by a thin layer of newly formed bone with 
fine, radial ridges on its surface. The left side was strength- 
ened by a thickly ossified lateral longitudinal ligament, en- 
compassing also the 1 0th costovertebral joint. 

Vertebra T8 also had a wedge-shaped body (anterior height 
5 mm, posterior height 20 mm) and it was firmly fused with 
the mentioned formation in intervertebral joints as well as by 

Zagreb Httleopathology Symp. I9H8 



Vertebral tuberculosis in ancient Egypt and Nubia • 183 




ABUSIR 
3CC/l/8'i 



Figure 1 . Case no. 1 . Thoracic spine with LI showing 
strongly arched deformity of T8-L1 , right lateral view. 





ABUSIR 



Figure 2. Case no. I. Lower third of thoracic and 
lumbar spine showing arched deformity of T8-L1, 
right lateral view. 




>'^-^-^% 



, V 



Figure 3. Case no. 1 . Wedge-shaped T8 and fused mass of 
bodies T9-12 united with Li, right lateral view. 

Zugreh Faleopalhalugy Symp. 1 988 



Figure 4. Case no. I. Owing to a bend of 130°. upper 
terminal plate of T8 and lower terminal plate of LI with a 
deep depression are visible in frontal view. 



184 • Eugen Strouhal 




Figure 5. Case no. 1. Deformity covered by ossified left 
lateral longitudinal ligament, encompassing 10th costover- 
tebral joint. 



ossification of the interspinal ligament. The intervertebral 
space T8-9 was preserved (height 2 mm) and there was also a 
wavy chink dividing the ossified left lateral longitudinal liga- 
ment. The right side of the body of T8 was bare. 

Intervertebral openings and the spinal canal did not show 
any reduction that could have caused neurological problems. 

The course of the vertebral column was deformed both in 
the frontal and sagittal planes. There was a slight, S-shaped 
scoliosis, sinistroconvex in the lumbar and lower thoracic 
sections, dextroconvex in the upper thoracic half. 

The kyphotic angulation reaching 1 30° appeared more im- 
portant. To compensate for this protuberance, the remaining, 
healthy lumbar vertebrae showed increased anterior heights 
compared with their posterior heights (L2 36/26, L3 34/30, 
L4 32/28, L5 32/26 mm). At the same time, the physiologi- 
cal thoracic kyphosis was reversed into a compensatory lor- 
dosis, in the section not involved in the pathology, by a 
similar increase of anterior heights compared with the pos- 
terior ones (T3 21/19, T4 20/18, T5 22/20, T6 23/20, T7 
22/21 mm). The remaining correction of the upright posture 
must have been achieved by hyperlordosis of the cervical 
spine and dorsal flexion of the head . Also with these compen- 
satory adaptations, the position of the lower thoracic spine 
was almost horizontal , causing deformation of the thorax and 
heavy pressure on thoracic and abdominal internal organs. 
The spinal deformation lowered substantially the living sta- 
ture of the man. The difference between the value calculated 




Figure 6. Case no. 1. Radiogram of right sacroiliac an- 
kylosis (afcovej, axial projection, and fused vertebrae T8-L1 
(below), lateral projection. 



according to lengths of long bones and the measurement of 
the body length in situ was 16.4 cm. In spite of these 
changes, the hunchback was able to walk (possibly with the 
help of a stick, whose head was put into his inner coffin) and 
work. 

The described changes could, by the unnatural twist of the 
spine, also have caused deep, oval depressions on terminal 
plates of the neighboring vertebrae LI + 2 and L2 -I- 3, signs 
of the prolapse of the nucleus pulposus of the intervertebral 
discs (Figures 4,5). Osteochondrosis of the intervertebral 
discs C5-6 and C6-7 and spondylarthrotic changes in the 
joints T6-7 and T8-9 may also have been associated with the 
adaptive changes of the gravity of the thoracic spine. 

SACROILIAC SYNOSTOSIS 

The right sacroiliac joint was ankylosed by means of a thick 
layer (up to 4 mm) of newly formed bone covering the ante- 
rior half of the upper margin and the upper half of the anterior 
margin of the facies auriculares (Figures 6,7). The remaining 
margins and the inner space were free. The left sacroiliac 
joint presented osteophytic lipping on the margins of both 
facies auriculares (2-5 mm). These changes could have been 
adaptive, strengthening the basis of the deformed spine. 

Zagreb Paleopathology Symp. 1988 



Vertebral tuberculosis in ancient Egypt and Nubia • 185 



Figure 7. Case no. 1. Synostosis of 
part of right sacroiliac joint, cranial 
view. 




ABUSIR 



OSTEOMA ON THE RIGHT FIBULA 

A longitudinally oriented oval, roundish protrusion (18 x 10 
mm, elevated 4 mm) was situated at the medial aspect of the 
distal end of the right fibula. Its surface was covered by 
compact bone, smooth or slightly uneven. 

CONGENITAL ANOMALIES 

A bilateral small foramen arcuatum atlantis (diameter 1 mm) 
was combined with bilateral, anteriorly open foramina trans- 
versalia atlantis. The left foramen transversale epistrophei 
was also open laterally and there was an anomalously small 
opening (diameter 2 mm) at the site of the right foramen 
transversale. 



DIAGNOSIS OF THE SPINAL PATHOLOGY. 

Features considered to be characteristic for spinal tuber- 
culosis in current paleopathological literature have been 
compared for both cases in Table 1 . Leaving aside age and 
sex, there are 20 features of which the majority fit for case 
no. I. There are, however, seven features which disagree 
with the scheme and need to be explained. 

The extent of the pathology usually involves two to four 
vertebrae (Manchester 1983:40; Zimmerman and Kelley 
1982:105), but occasional cases may involve considerably 
more (examples are quoted by Zimmerman and Kelley 
1982:105), as shown by our case. Lack of the progressive 
erosion of the circumferential surface of vertebral bodies 
betrayed the termination of the activity of the disease. The 
same applied for the absence of a recent central abscess 
cavity in any of the vertebrae. In the course of the process, 
which was limited only to vertebral bodies, no changes lead- 

Zafirrb Paleopatbolony Symp. 1988 



ing to narrowing of the intervertebral openings or of the 
neural canal occurred. Paravertebral abscesses, derived from 
original abscesses in vertebral bodies T8-L1 , apparently did 
not affect any bony surface to leave observable changes. Not 
every patient with tuberculosis must be emaciated. Our case 
indicates a successful course of the disease thanks to the 
extraordinary resistance of the host. 

The strong kyphotic curvature observed in our case, in- 
stead of an angular nick, also can be reconciled with the 
diagnosis of .spinal tuberculosis. It was the result of summa- 
tion of six lesser angular kyphoses which gradually devel- 
oped after evacuation of the abscesses and pathological frac- 
tures of bodies of the afflicted vertebrae. 

COURSE OF THE DISEASE 

The infection must have begun early in childhood as evi- 
denced by the adaptive greater increase of anterior heights of 
the healthy vertebrae. It is well known that before the devel- 
opment of an effective therapy, vertebral tuberculosis devel- 
oped during the first decade of their life in 50-10% of tuber- 
culous children and usually appeared 9 months to 2 years 
after the primary infection (Ulrich-Bochsler et al. 1982: 
1 322). Other authors also stress the onset in early childhood, 
mostly before 7 years of age (Ortner and Put,schar 198 1 : 145). 
From the beginning of the disease in his first decade of life 
the affiicled man lived 30-50 more years, during which com- 
plete healing occurred except for the preservation of the de- 
formity of the spine by firm fusion of the remnants of the 
involved vertebral bodies. It seems highly probable that dur- 
ing this long period his immune response succeeded in sub- 
duing also other possible manifestations of bacillus Kochi in 
his other organs. 



186 • Eugen Strouhal 



Table l. Comparison of characteristic features of spinal tuberculosis of 
cases 1 and 2 



Feature 


Case no. 1 


Case no. 2 


Age at death 


40-50 yr 


ll-l'^yx 


Sex 


male 


male 


Thoracolumbar localization 


+ (T8-LI) 


+ (T1-L5) 


Extent 


6 vertebrae 


17 vertebrae 


Progressive erosion of 


- 


+ 


circumferential aspect 






of body 






Central abscess cavity 


- 


+ (Til) 


within vertebral body 






Wedge-shaped vertebral body 


+ (T8-L1) 


+ (Til, LI) 


Complete healing of body 


+ (T8-L1) 


+ (LI) 


without residual cavity 






Fusion of vertebrae with 


+ 


- 


destruction of 






intervertebral discs 






Noninvolvement of neural 


+ 


- 


arch and its processes 






Secondary arthritis and 


+ 


-f 


ankylosis of inter- 






vertebral joints 






Ossification of inter- 


+ 


- 


spinous ligaments 






Ossification of lateral 


+ (left) 


- 


longitudinal ligaments 






Apposition of new- 


+ (right) 


- 


formed bone 






Fusion of costovertebral 


+ (left lOlh) 


- 


joints 






Compensatory growth of 


+ 


- 


healthy vertebral bodies 






Narrowed intervertebral 


- 


+ (right T9 - 10) 


openings 






Narrowed neural canal 


- 


- 


Kyphosis 


■>■ (strong bend) 


+ (double angle) 


Scoliosis 


■^ (S shaped) 


+ (dextroconvex) 


Evidence of paravertebral 


- 


+ (bilateral) 


abscess 






Corporal emaciation caused 


- 


- 


by advanced tuberculosis 







DIFFERENTIAL DIAGNOSIS 

Most other diseases that can cause a similar picture, listed by 
Steinbock (1976; 176, 179), are systemic, and leave traces 
also in other skeletal locations, which were not found in our 
case. The possibility of a healed compression fracture, how- 
ever, has to be considered, although usually only a single 
vertebra is involved. Its areas of predilection arc the cervical 
and upper thoracic spine. Destruction of the vertebral body is 
less extensive than observed in our case (Ortner and Putschar 
1981 : 149). We may add that on radiograms a diagonal break 
may be detected and that the intervertebral spaces usually 
remain intact. 



SOCIAL IMPLICATIONS 

Our patient very probably must have been nursed during the 
initial period of his disease in childhood. After healing was 
completed and the deformity of his spine became fixed, he 
was able to be self-sufficient and lead a normal way of life. It 
could have been precisely because of his curious external 
appearance that he was considered a "sacred" person, and 
buried in the area of the Pyramid Temple of Raneferef. Tuber- 
culosis was not connected with his death. 



Case number 2 

ARCHEOLOGICAL BACKGROUND 

In tomb no. 87 of cemetery K situated on the slope of the left 
Nile bank west of the fortified settlement at Nag'el-Scheima 
(area of recent Sayala, 130 km south of Aswan), an adult 
skeleton was lying stretched out in the supine position with 
head to the west and arms alongside the body. There were no 
funeral offerings in the tomb. Together with other burials of 
cemetery K, serving the common people of the fortified set- 
tlement, the tomb dates from the Christian period (6th- 1 1th 
century a.d.). 

EMBALMING METHOD 

No traces of an attempt to preserve the body by mummifica- 
tion were found. 

AGE 

All cranial sutures were still open except for beginning of 
fusion in the lateral thirds of the coronal suture (C3). In the 
mostly preserved dentition (only upper right 12 and C and 
lower left 1 1 were missing and both upper I I , upper left C 
and lower right II showed broken-off crowns) we found fully 
erupted third molars and only the beginnings of attrition of 
the dentine (points) in most of the teeth. At the same time, 
both lower M2 were already lost and their alveoli closed. The 
crown of the lower right M 1 was devoured by a caries leaving 
in situ only roots surrounded by a periapical abscess cavity. 
Both lower M3 showed occlusal caries, greater right (diame- 
ter 3 mm) than left (diameter 1 mm). Premature incidence of 
caries, already beginning in deciduous dentition, is a com- 
mon feature of the population of Sayala during the Christian 
period. Resorption of the alveolar process was only slight 
according to the scale of Brothwell ( 1 963: 1 50) with incipient 
atrophy of the alveolar process around both lost lower M2. 
Beginnings of deposition of dental calculus could be ob- 
served. 

Most of the epiphyseal and apophyseal fissures were com- 
pletely closed, except between bodies SI and S2 of the sac- 
rum and on the medial ends of the clavicles. Moreover, traces 
of recent epiphyseal or apophyseal fusion could be detected 

Zanreh Pttleoputholo^y S\mp. I98fi 



Vertebral tuberculosis in ancient Egypt and Nubia • 187 



on terminal plates of the cervical vertebrae, between other 
sacral bodies, along the cristal and ischiatic apophyses, on 
humeral and femoral heads as well as on the distal ends of 
radii, ulnae and fibulae. The pubic symphysis showed pha.se 
3 of Todd ( 1920) having the range of 22-24 years. Parts of 
the sternum were not fused. No age-dependent changes could 
be found on the proximal ends of both humeri and femora, 
except some rugged relief medially on the crista tuberculi 
maoris, caused by muscular action. There was no arthritis, 
no patellar and only beginning calcaneal osteophytes. On 
vertebral bodies whose margins were not eroded by the 
pathological process to be described (CI-T4, L2-5, SI ) no 
lipping was present except slight beginnings on C4 and C5. 
Also the intervertebral joints were intact except in the region 
mostly involved in the pathology, where an arthrosis of T9- 
10 and synostosis T 1 0-1 1 developed. 

The described features agree with a young adult age of 22- 
24 years. 

SEX 

In spite of an only slightly developed glabella (Broca 2) and 
supraorbital arches (Eickstedt 2) as well as a nasofrontal 
transition in an only slightly concave arch and a very feeble 
protuberantia occipitalis externa (Broca I), other features 
pointed to the male side. There was a smoothly arched fore- 
head, a thick and long mastoid process, a small and shallow 
incisura mastoidea. situated within the mass of the process, a 
moderately thick orbital margin, a slightly to moderately 
developed processus marginalis, a slightly to moderately de- 
veloped nuchal, but a medium to strongly marked mandibu- 
lar muscular relief with a large eversion of the mandibular 
angle. Also moderately large pelvic apophyses, a deep and 
narrow ischiatic notch, absence of a preauricular sulcus, an 
oval, moderately large pelvic inlet, an outstanding tuber- 
culum pubicum, a flaring lower aspect of the pubic bone, a 
rather acute subpubic angle (60°) and a low ischiopubic index 
(left 64.0, right 63.6, according to Thieme and Schull 
1957:269) argued unequivocally for the male sex. 

GENERAL PHYSICAL FEATURES 

The body build was moderately robust to robust with well- 
developed muscular insertions. Stature, reconstructed ac- 
cording to tables of Trotter and Gleser (1952) for American 
Negroes, was medium (166.1 cm). 

SPINAL PATHOLOGY 

In contrast with case no. I , the whole thoracic and lumbar 
spine showed a lytic process with inhibition of new bone 
regeneration, progressing from above downward in the thor- 
acic and from below upward in the lumbar section with max- 
imum changes in TIO-LI, resulting in a double angular 
kyphosis (Figures 8-13). Multiple small, larger, and big 

Zu^reb Faleopalholony Symp. I98S 




Figure 8. Case no. 2. Upper thoracic spine with lytic 
changes on vertebral bodies, right lateral view. 



confluent cavities were characteristically localized on the 
circumferential aspects of the vertebral bodies, portraying 
the hematogenous spread of the infection via the paraver- 
tebral plexus and anterior longitudinal ligament (Zimmer- 
man and Kelley 1982:105). 

The cervical spine was devoid of pathological changes. 
The upper third of the thoracic spine showed eroded pits on 
the vertebral bodies, whose original shape had been mostly 
preserved. In the middle part of the thoracic spine the de- 
struction by confluent foci reached such an extent that only 
stumps of vertebral bodies remained. They had bizarre forms 
of columns bordering deep cavities and perforations. The 
process did not penetrate into the neural arch and no changes 
were present on intervertebral joints. 

The lower part of the thoracic spine was maximally af- 
flicted by the pathology. The lytic process removed the whole 
body of vertebra TIO and eroded the anterior parts of the 
pediculi arcus vertebrae. The anteroposterior axis of the ver- 
tebra had been rotated 70°, and consequently the spinous 
process of T9 became the salient point of an angular kyphosis 
(90°). Intervertebral joints T9- 10 were enlarged and eroded 



188 • Eugen Strouhal 









^■4. 



IT 



^jpr 



Figure 10. Case no. 2. Lower thoracic spine with lytic 
changes and angular deformity of T 10- 12, right lateral view. 

Figure 9 (left). Case no. 2. Upper thoracic spine with lytic 
changes on vertebral bodies, frontal view. 




-^^■r 



Co 



Figure II. Case no. 2. Lower thoracic spine with lytic 
changes, completely destroyed body Tl 0, and wedge-shaped 
body Til, frontal view. 



-W" 



= «t 




Figure 12. Case no. 2. Lumbar spine with wedge-shaped 
LI, lytic cavities in body L2, and more or less pitting in 
bodies L3-5, right lateral view. 

Zagreb Paleopathology Symp. 1988 



Vertebral tuberculosis in ancient Egypt and Nubia * 189 










Figure 13. Case no. 2. Lumbar spine with 

wedge-shaped LI, lytic cavities in body 

L2, and more or less pitting in bodies L3- Figure 14. Case no. 2. Radiogram of spine showing lytic changes and double 

5, frontal view. angular kyphosis, which together equals 140°, lateral projection. 



(spondylarthritis), while joints TlO-ll were completely 
fused (synostosis). These changes were secondary to un- 
usually heavy strain. 

The wedge-shaped vertebra Tl 1 (anterior height 4 mm, 
posterior height 20 mm) showed in its center a large abscess 
cavity, bordered by lateral pillars of the remaining spongiosa, 
thicker right (8-1 1 mm) than left (5-6 mm). Thebody of this 
vertebra filled the empty space in the place of the destroyed 
body TIO by rotation of the anteroposterior axis of the ver- 
tebra including 90° with the axis of T9. Articular facets of the 
intervertebral joint TII-12 were enlarged but not eroded. 

Vertebra T12 retained its original shape, but its whole 
surface had been eroded by several large and partly merging 
cavities. Small saucer-shaped erosions penetrated also into 
both pediculi arcus vertebrae. Intervertebral joints TI2-LI 
did not show any change. 

Another wedge-shaped vertebra L 1 (anterior height 3 mm, 
posterior height 21 mm) revealed that the lytic prwess con- 
tinued after the evacuation of the abscess and healing of the 
pathologically fractured vertebral body. There were several 
small or medium cavities and erosions on its surface (upper, 
right lateral, and lower margin). Even both pediculi arcus 
vertebrae were perforated from above (5x7 mm) downward 

Zagreb Paleopathology Symp. 1988 



(1x1 mm) and the anterolateral side of the right processus 
articularis superior showed two tiny "borings." Owing to the 
wedge shape of L 1 , its spinous process was the top of another 
angular kyphosis of the spine (50°). 

Vertebra L2 retained its original shape, but several large 
cavities penetrated its surface (anteriorly left of the midline, 
on the left and right anterolateral aspect) together with small- 
er pits and erosions. 

The following vertebrae L3-5 showed a decreasing quan- 
tity of pitting, on a few places merging into larger defects. 
Here we could observe well the progress of the described 
process. All lumbar intervertebral joints were intact. 

The axis of the spine deviated in the sense of a dex- 
troconvex scoliosis of the lower thoracic section. More im- 
fwrtant, however, was the double kyphosis in the thor- 
acolumbar transition reaching collectively an incredible 140° 
angle. The deformation of the vertebral column can be seen 
on the radiogram (Figure 14) together with the extent of 
erosion and destruction of the individual vertebrae. Because 
of absence of a compensatory growth of the vertebrae in the 
sense of an adaptive lordosis, the thoracic spine starting at the 
thoracolumbar bend in vivo was sinking from above back- 
ward to downward and forward in a very oblique position. 



190 • Eugen Strouhal 




Figure 15. Case no. 2. Eroded area 
with new bone overgrowth on inner 
side of right iliac wing, frontal view. 



''1 




I 


1 


■ii' 




] 


» 




v 


IP- 


\ 






■ 


I- 

r 




« 




P 


i 



Figure 16. Case no. 2. Eroded area 
with new bone overgrowth on inner 
side of left iliac wing, frontal view. 



The deformed thorax and the abdomen were very much com- 
pressed into the narrow space between the lumbar and thor- 
acic spine, making the function of internal organs extremely 
difficult. The only possibility to maintain the quasi- 
horizontal position of the head was an exaggerated cervical 
and atlanto-occipital hypcrlordosis. 

DEMARCATED ILIAC PERIOSTITIS 

Unusual findings on the upper parts of the inner aspects of 
both wings of the iliac bones were almost certainly connected 
with the described spinal pathology. There were crescent- 
shaped segments of eroded compact bone, revealing the thick 
spongiotic bone. On the lower borders of the erosions and in 
a few places inside the erosions there were spiculae, iippings 
and islets of newly formed, compact bone (Figures 15.16). 



On the right iliac bone the defect began on the crista iliaca 
67 mm anterior to the spina iliaca posterior superior and 
extended with a caudally convex border (maximum distance 
from the crista iliaca 27 mm) to a point 84 mm posterior to the 
spina iliaca anterior superior. The erosion encompassed aLso 
the crista iliaca between the points mentioned. 

On the left iliac bone the extent of the defect was narrower 
and shorter than on the right one. It began about 70 mm 
anterior to the spina iliaca posterior superior and extended 
with a wavy, inferior border (maximum distance from the 
crista iliaca 19 mm) to a point 95 mm posterior to the spina 
iliaca anterior superior. 

The described changes may be considered reactive to tem- 
porary adherent "cold" abscesses, descending paraverte- 
brally on the posterior side of the large and small psoas 
muscles. 

Zagreb Paleopaihnhny Symp. 1988 



Vertebral tuberculosis in ancient Egypt and Nubia • 191 



DIAGNOSIS 

Comparing characteristic features of tuberculosis in case no. 
2 with case no. 1 (Table 1), we find differences in more than 
half of them. Case no. 1 findings indicated a long duration 
with prevalence of adaptive changes and healing. In contrast 
to this, case no. 2 showed a relatively short-term and active, 
predominantly lytic process with very limited healing. 

At the same time, with half of the features there seems to 
be a disagreement with the usual diagnostic set for tuber- 
culosis. This applies first to the extraordinarily great extent 
of the process, involving altogether 17 vertebrae with major 
changes in four of them. From the recent literature two cases 
with similarly elevated numbers of afflicted vertebrae can be 
quoted. The first one from Oberweil bei Buhren a.d. Aare 
(Switzerland), dated 7th-8th century a.d., was that of an 
18-23-year-old woman afflicted by a destructive-reparative 
process involving 13 vertebrae, C7 and all thoracic with 
maximum changes between T4 and T6 (Ulrich-Bochsler et 
al. 1982:1318-1319). A juvenile male aged about 15 years 
from Arene Candide Cave (Liguria, Italy), dated beginning 
of the 4th millennium B.C., showed resorptive lesions in 
eight vertebrae (T9-L4) with a maximum of destruction be- 
tween TIO and LI (Formicola et al. 1987:3). Cases with a 
great extent of the process most probably reflect the great 
virulence of infection and the limited resistance of the host. 

In agreement with that we found the uncommon involve- 
ment of anterior sections of the neural arch (pedicles and 
articular processes) which characterizes very severe cases 
(Zimmerman and Kelley 1982:105). 

Because the process was relatively rapid and destruction 
dominated production of new bone, there was not enough 
time and resistance for the development of fused vertebral 
bodies, ossification of interspinous or lateral longitudinal 
ligaments, apposition of new-formed bone, or fusion of cos- 
tovertebral joints. Steady progression of the destruction over 
healing was revealed especially in LI whose "healed" wedge 
shape was eroded anew by suppuration. 

The process did not nartow the neural canal, but did in- 
volve a single intervertebral opening. Absence of compensa- 
tory growth of vertebrae was connected with the later begin- 
ning of the disease and lack of emaciation together with its 
relatively short duration. 



psoas abscesses is attested by the bilateral development of the 
demarcated iliac periostitis. The patient did not develop 
enough resistance and the infection spread both in the cranial 
and caudal directions gradually involving more and more 
vertebrae. 

Due to the severity of the infection and the extreme grade 
of deformation of the trunk we may be almost sure that the 
patient died as the result of it or from some of its complica- 
tions. The mortality of tuberculosis in the preantibiotic era 
was 50% and most often occurted in the first two decades of 
life. Today it is about 5% and confined to an adult or senile 
age (Ulrich-Bochsler 1982:1322). 

DIFFERENTIAL DIAGNOSIS 

The absence of pathological changes in the remaining skel- 
eton, revealed macroscopically and by the x-rays, as well as 
the evidence of the psoas abscesses are strong arguments 
against other diagnostic possibilities (Steinbock 1976:176, 
179). The multiplicity of lytic foci in such a great number of 
vertebral bodies could be produced by blastomycosis, but in 
it the lesions are almost only destructive, with a punched-out 
appearance and with little new bone growth. It involves also 
neural arches and, beside the spine, affects ribs and other 
bones (Zimmerman and Kelley 1982:89). In pyogenic os- 
teomyelitis of the spine such a great extent and massive de- 
struction of several vertebral bodies leading to an angular 
kyphosis and paravertebral abscesses are uncommon (Ortner 
and Putschar 1981:149). The pus, penetrating bone cortex, 
leads to new bone formation with irtegular thickening and 
cloacae in the involucrum (Zimmerman and Kelley 1982:93- 
94). 

SOCIAL IMPLICATIONS 

The rapid progression and severity of the process forced the 
patient to lie in his bed and be nursed by his family or neigh- 
bors. The exaggerated deformity of the spine with extreme 
compression of internal organs prevented standing, walking 
and working. He became fully dependent on social support. 
This state did not last, however, for a long time. The short 
course of the disease is reflected in the preservation of his 
relatively robust and muscular body. 



COURSE OF THE DISEASE 

Our young man caught the disease after the end of his growth 
period, since otherwise adaptive increase of anterior heights 
of vertebrae would have appeared. With regard to his age at 
death, there is a span of about seven to nine years in which the 
process could occur. It seems, however, probable that it 
lasted for a far shorter period. Most probably the body of TIO 
was first destroyed, later an abscess involved the left LI, and 
finally another abscess was evacuated from Til, leaving 
there remnants of its cavity. More than a single extension into 

Zannb Paleopalhotogy Symp. 1988 



Literary data on vertebral tuberculosis 
in Egypt and Nubia 

Since it is a disease of at least neolithic antiquity, associated 
with drinking milk of cows infected by the bovine type of 
Mycohacterium tubercuhsia, from which the human type 
developed later by microevolution (Manchester 1983:39- 
40), the occurrence of tuberculosis in ancient Egypt and 
Nubia may well be expected. Milking there became very 
important as expressed in the widespread cult of the cow- 
goddess Hathor, and there was a high population density in 



192 • Eugen Strouhal 



crowded villages and towns which enabled close contact of 
people and easy transmission of the agent. 

Three different sources of information, scattered in the 
literature, may be consulted for a survey of the presence of 
vertebral tuberculosis: iconography, excavated skeletal re- 
mains, and mummies. 



ICONOGRAPHY 

Several statues and drawings of hunchbacks may be found in 
Egyptian art (Morse et al. 1964:525-528; Morse 1967:263; 
Baud 1978:pl.l6). Their evidence is, however, ambiguous. 
Diagnosis of vertebral tuberculosis can be based only on the 
shape of the kyphosis. If it is angular, the probability of 
tuberculous origin is great. If it is arched, other diseases such 
as rachitis, Scheuermann's disease, osteoporosis, and bad 
body posture also must be taken into account. 

Better information may be gained in plastic art. The diag- 
nosis of vertebral tuberculosis is suggested in an allegedly 
predynastic clay statuette of an emaciated man with a thor- 
acic angular kyphosis found inside a bowl (Morse et al. 
1964:524-525), a possibly predynastic standing, ivory fig- 
ure showing protrusion of the back and chest (Morse et al. 
1964:525), a probably Archaic statuette of a squatting, 
bearded man with a thoracic angular protuberance and an 
angular protrusion of the chest (Jonckheere 1948), and a 
wooden statue from the Cairo Museum with an angular 
kyphosis on the transition between upper and middle third of 
the thoracic spine (Ghalioungui and Dawakhly 1965:20, 
fig.64). 

In drawings, evaluation is more complicated, because the 
hunchback can also be factitious due to artistic ineptitude and 
stylistic convention. In Egyptian pictures, human shoulders 
traditionally were represented in frontal view and if the artist 
failed to place one of the arms correctly the protruding shoul- 
der may resemble a strongly arched hunch, situated high on 
the spine. This can be the case of the representation of the 
"deformed" gardener from the New Kingdom tomb of Ipuy 
(Davies 1927:pl.XXIX), of the relief of the priest Ankhutus 
from the false door of his Old Kingdom tomb (Mogensen 
1930:90, pi. XCV), as well as of the relief of a servant leading 
two dogs in the Ti's Vth dynasty tomb (SteindorflF 1913: 
pi. 1 15). Only the relief of a serving girl from tomb no. 45 at 
Giza, dated IVth dynasty, shows a strongly arched thoracic 
protuberance (Vandier I964:rig.2), and the painting of an 
attendant from a Xllth dynasty tomb at Beni Hasan demon- 
strated a protruding, arched hump at the cervicothoracic tran- 
sition, both suggesting tuberculous origin. 



SKELETAL REMAINS 

Altogether, 30 cases of vertebral tuberculosis were gathered 
in the last reviews of tuberculosis in ancient Egypt by Morse 



et al. (1964:529-540) and Morse ( 1967:263-268). There are 
13 cases from the Upper Egyptian site at Nagada with "typi- 
cal pathological changes to be considered as tuberculosis and 
seven of them . . . quite typical" (Morse 1967:268). Unfor- 
tunately, their dating is problematic. While some are pre- 
dynastic (B 107, T 52), others may come from dynastic times 
upto 1400 B.C. In six cases (B 107,60, 1003, D5, R, andQ) 
the diagnosis of tuberculosis seems to be less probable, and 
other causes (such as acute osteomyelitis or healed com- 
pressed fracture) were also taken into consideration (Morse 
etal. 1964:535-539). 

Of the nine cases described by Derry (1938:1) and sum- 
marized in a table by Morse (1967:264) only two were from 
Egypt, one found in an aged woman from Saqqara dated as 
early as 3300 B.C. , and the other in an old woman from Deir 
el-Bahri dated 1500 B.C. Seven other cases come from 
Nubia, most of which are dated 3000 b.c. , and in case no. 1 , 
2000 B.C. Four adult men, two adult women and a nine-year- 
old boy were afflicted. Epidemiologically interesting are two 
graves, each containing remains of two tuberculous individu- 
als (a man with a woman in tomb no. 314, and a man with a 
boy in tomb no. 452). 

A series of six unfortunately isolated Nubian vertebral 
specimens were described by Morse et al. (1964:531-534) 
and summarized by Morse (1967:265). One of them listed 
under catalog no. 1 82 E, together with vertebrae of two other 
persons, is identical with Derry 's case no. 1 , being a lumbar 
vertebra with a large smoothly delimited cavity more sugges- 
tive of a bone cyst or osteolytic neoplasm (Morse et al. 
1964:533, fig. 9 above right) and should be excluded. 

Another case of vertebral tuberculosis was described by 
Smith (1927:24) and quoted by Morse et al. (1964:534). but 
insufficiently quoted by Morse (1967:265,267). In the in- 
complete remains of Pa-Ra'messu, the son of Seti I and 
brother of Ramesses II, aged 26-30 years, a mass consisting 
of six thoracic vertebrae (probably T4-9) with parts of corre- 
sponding ribs was found, all firmly ankylosed together. The 
bodies of the middle vertebrae had collapsed causing a right- 
angle bend between probably T6-7. Smith associated with 
this process the slendemess and gracility of the left leg com- 
pared with the right one. 

The case described by Watermann (1960:170-171) has 
been misquoted by Morse et al. (1964:531) and Morse 
(1967:264) as originating at Giza and excavated by Abu 
Bakr. In reality it was found in a prehistoric grave and stored 
in the Museum of Helwan. Two fused sections of the spine 
were apparent, the first between T4 and T7 with wedge- 
shaped bodies and another between L I and L5 with a wedge- 
shaped body L3 . In both areas neural arches were massively 
involved, making the diagnosis of tuberculosis somewhat 
doubtful (Morse etal. 1964:531). 

To this survey we may add another case of a middle-aged 
male found in shaft no. 42 of the uninscribed mastaba B near 
the Pyramids of Giza with wedge-shaped vertebrae TIO and 



Zagreb Paleopathology Symp. 1988 



Vertebral tuberculosis in ancient Egy pt and Nubia • 193 



T 1 2 and less compressed T 11 . In spite of the expressed diag- 
nosis of a "chronic rarefaction" leading to "gradual compres- 
sion of the . . . vertebrae" (Abadir 1953:85), tuberculous 
origin of the condition cannot be excluded as well. 

MUMMIES 

Notwithstanding the fact that large series of Egyptian mum- 
mies have been subjected to radiological and other scientific 
studies in the two recent decades, cases with vertebral tuber- 
culosis remain rare. There is the often-quoted hunchback 
priest of the god Amun called Nesperehan, detected among 
44 well-preserved mummies found by Grebart in 1891 
(Smith and Ruffer 1910: Smith and Dawson 1924:156, 
fig. 62; Cave 1939:142). His mummy shows destruction of 
the lower thoracic and upper lumbar vertebrae causing an 
angular kyphosis and a large abscess cavity in the area of the 
right psoas muscle. 

In the most probably natural mummy of a 5-year-old child 
from an intrusive burial ( 1000-400 B.C.) found in the tomb 
of Nebwenenef at Thebes, pulmonary and vertebral tuber- 
culosis ending with a fatal hemorrhage was described and 
tuberculous bacilli proved in the vertebral bones (Zimmer- 
man 1979). 

Discussion 

Together with our two cases, 6 iconographic, 30 skeletal, and 
2 mummy specimens attest with lesser or greater probability 
the presence of vertebral tuberculosis in ancient Egypt and 
Nubia. Of the skeletal cases, 19 were from Egypt and 13 
from Nubia with no particular preference for either of the two 
countries. Unfortunately it is not possible to guess how many 
vertebral columns were examined by anthropologists experi- 
enced in pathology and what was the incidence of the dis- 
ease. The accumulated number of cases discloses, however, 
that it was by no means negligible. 

Our case no. 1 comes from an isolated Middle Kingdom 
tomb inserted in the ruins of an Old Kingdom temple at 
Abusir. No data on the frequency of the disease, therefore, 
can be given. 

Our case no. 2 was found in the Christian cemetery at 
Sayala. The total number of identified individuals was 161 . 
In no other individual of this group could we detect changes 
pointing to tuberculosis. Thus a rough estimate of incidence 
would be 0.62% . Because vertebral tuberculosis accounts for 
1-3.5% of the incidence of tuberculosis in all its forms, this 
would mean that 1 8-62% of people could have been infected 
by tuberculosis at Sayala. Together with other unknown 
causes this could explain the extremely low mean age at 
death of its Christian population (about 18 years). 

The scarcity of findings of vertebral tuberculosis in ar- 
tificially mummified bodies (representing members of the 
high social stratum that could afford costs of mummification) 



could well reflect social differences in the incidence of tuber- 
culosis. However, if we consider that some of the skeletal 
remains could represent disintegrated mummies (as our case 
no. 1 and possibly also the remains of the royal son Pa- 
Ra'messu), there would be 3 cases out of the total of 32 
belonging to the royal and priestly society. The incidence 
(9.4%) does not seem to be significantly smaller than the 
supposed percentage share of the high stratum in the ancient 
Egyptian society. 

In the present state of our knowledge these reflections can 
be no more than preliminary. Much research should be per- 
formed in the future, aiming at establishing reliable data on 
the incidence of vertebral tuberculosis, the excellent marker 
for studies of tuberculous infection in different periods, re- 
gions, and social layers. They are especially important for 
reconstruction of the social history of ancient Egypt and 
Nubia. 



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16. Leipzig, GDR. 

Steinbock, R.T 1976. Paleopathological Diagnosis and Interpre- 
tation. Springfield, III.: Charles C Thomas. 

Steindorff. G. 1913. Das Grab des Ti. vol. 2. Leipzig, GDR: J.C. 
Hinrichs'sche Buchhandlung. 

Strouhal, E. 1986. Embalming Excerebration in the Middle King- 
dom. In A.R. David, ed. , Science in Egyptology: Proceedings of 
the Science in Egyptology Symposia, 141-154. Manchester, 
U.K.: Manchester University Press. 

Strouhal, E., and J. Jungwirth. 1984. Die anthropologische Unler- 
suchung der C-Gruppen- und Pan-Graber-Skelette aus Sayala, 
Aegyptisch-Nubien. Osterreichische Akademie der Wissenschaf- 
ten, phil.-hist. Klasse, Denkschriften, 176. Band. Vienna: Ver- 
lag der Oesterreichischen Akademie der Wissenschaften. 



Thieme, F.P., and W. Schull. 1957. Sex Determination from the 
Skeleton. Human Biology, 29:242-273. 

Todd, TW. 1920. Age Change in the Pubic Bone. American Jour- 
nal of Physical Anthropology. 3:285-334. 

Trotter, M., and G.C. Gleser. 1952. Estimation of Stature from 
Long Bones of American Whites and Negroes. American Journal 
of Physical Anthropology, 10:463-514. 

Ulrich-Bochsler, S., E. Schaublin, TB. Zeltner, andG. Glowatzki. 
1982. Invalidisierende Wirbelsauleverkrummung an einem Skel- 
ettfund aus dem Fruehmittelalter (7./8. bis Anf.9. Jhr). Ein Fall 
einer wahrscheinlichen Spondylitis tuberculosa. Schweizerische 
Medizinische Wochenschrift, 112:1318-1323. 

Vandier, J. 1964. Manuel d'Archeologie Egyptienne. Tome IV. Bas 
Reliefs et Peintures. Scenes de la Vie Quotidienne. Paris: Picard. 

Watermann, R. I960. Palaeopathologische Beobachtungen an alt- 
aegyptischen Skeletten und Mumien. Homo, 1 1:167-179. 

Zimmerman, M.R, 1977. The Mummies of the Tomb of Neb- 
wenenef: Paleopathology and Archeology. American Research 
Center in Egypt, 14:33-36. 

1979. Pulmonary and Osseous Tuberculosis in an Egyptian 

Mummy. Bulletin of the New York Academy of Medicine. 55: 
604-608. 

Zimmerman, M.R.,andM.A. Kelley. \9S2. Atlas of Human Paleo- 
pathology. New York: Praeger. 



Summary of audience discussion: These two cases each demon- 
strate a very large diseased area involving 8 to 10 vertebrae. In the 
absence of vertebral body destruction a mycotic etiology might be 
considered. These, however, are rare in Egypt and the second case 
does show two foci of vertebral body destruction. The bilateral 
nature of sacral involvement is unusual . yet cannot be explained as a 
nontuberculous, mechanical abrasion. 



Zagreb Paleopathology .Symp. 1988 



Leprosy 



Leprosy and tuberculosis in the Byzantine 
monasteries of the Judean Desert 

Joseph Zias 



In his classic work of 191 1 on biblical 
medicine, the German physician J. 
Preuss noted that there were nearly as 
many books and treatises on the subject 
of biblical leprosy as there were on cir- 
cumcision in the Bible (Preuss 1978). 
However, despite the plethora of writ- 
ten information on this ancient disease 
which, according to literary sources, 
existed as early as 600 B.C., scant ar- 
cheological evidence of leprosy exists 
prior to a.d. 1200. In fact, prior to the 
publication of Preuss's encyclopedic 
work, there had been only one find 
from the postbiblical period (a.d. 5(X)) 
in Nubia (Smith and Dawson 1924). 
Even today, despite the intense world- 
wide activities of archeologists and 
physical anthropologists, no indisputa- 
ble physical evidence of the disease has 
been found, with the exception of iso- 
lated instances in the United Kingdom, 
North Africa, and the cemeteries of me- 
dieval Danish leprosaria. In Israel, 
where evidence of man's presence is 
over one million years old, and where 
thousands of skeletal remains have 
been uncovered, evidence of leprosy 
has eluded us. In fact, S.G. Browne 
noted in 1975 that not a single case had 
ever been found in ail of the Fertile 
Crescent. 

In the spring of 1983, excavations 
were carried out at the Judean Desert 
monastery of Martyrius, which had 
been founded in the fifth century and 
destroyed by the Persians in a.d. 614, 
never to be rebuilt. Here a common 
grave was discovered in an ancient 
church fioor, dated by inscription to 

Zagreb Paleopathology Symp. 1968 



492. The grave contained the skeletal 
remains of nine men and one woman, 
four of whom showed bilateral mutilat- 
ing changes on the hands and feet 
which were originally thought to be as- 
sociated with leprosy (Figure I ). Sub- 
sequent study of the material by the au- 
thor with American and European 
specialists in paleopathology showed 
that our original diagnosis of leprosy 
was incorrect. Despite the widespread 
involvement of the small bones of the 
extremities with numerous lytic de- 



.rf^ 




structive foci, the concentric absorp- 
tion of the phalanges, metatarsal and 
metacarpal bones, which is common in 
leprosy, was absent. Moreover, three 
individuals showed ankylosis of the 
vertebral column and the sacroiliac 
joint, which is not usually associated 
with leprosy. The widespread skeletal 
involvement of the disease with varying 
degrees of architectural destruction 
suggests that psoriatic arthritis is the 
preferred clinical diagnosis rather than 
leprosy as was earlier reported (Zias 








Figure I. Phalanges of the hand. (Courtesy of Israel Antiquities Authority. T 
Sagiv) 

197 



198 • Joseph Zias 




Figure 2. Hyena feces showing textiles and human bone. (Courtesy of Department 
of Antiquities, Ministry of Education and Culture, State of Israel — T. Sagiv) 



1985). Since psoriatic arthritis affects 
both the skeleton and the skin of the 
individual, it mimics to a certain extent 
those changes usually associated with 
leprosy, which may have been the rea- 
son for inclusion in the Byzantine mon- 
astery. Literary evidence from the Med- 
iterranean area indicates that the Early 
Church established hospitals for the 
care of those suffering from leprosy as 
early as the fourth century a.d. (Avi- 
Yona 1963). Therefore it seems entirely 
plausible that these four individuals 
may have been mistaken as suffering 
from leprosy and sought refuge in the 
desert monastery of Saint Martyrius. 

Following this discovery, we ob- 
tained permission from the Greek Pa- 
triarch to survey the few Byzantine 
monasteries possessing skeletal collec- 
tions dating from the Persian massacres 
of A.D. 614. This survey, however, did 
provide evidence of leprosy in the Holy 
Land during the seventh century and 
earlier. 

In the summer of 1983 we were noti- 
fied of the accidental discovery of a 
mass grave at the Monastery of John the 



Baptist near the Jordan River where, 
according to Christian tradition, the 
"washing of the lepers" took place 
(Hoade 1981). Most of the grave had 
been destroyed by a bulldozer; how- 
ever, we managed to retrieve 34 skel- 
etons which were dated by ''*C to ap- 
proximately A.D. 600. Owing to the 
unique environmental conditions (400 
meters below sea level, minimal hu- 
midity and rainfall), preservation was 
excellent. One interesting aspect of this 
find is that some of the burial customs, 
such as placing seeds from the tree Bal- 
anites aegyptiaca in the hands of the 
deceased, conform to ancient Egyptian 
traditions, suggesting that these indi- 
viduals had traveled for some consider- 
able distance prior to their deaths. 
Among the human remains were feces 
(subsequently identified as those of a 
hyena) which contained fragments of 
human hair, bone, and remnants of the 
same cloth found in the grave, suggest- 
ing that those buried here had been 
killed in the Persian massacre of a.d. 
614 and had been buried only hours or 
days later (Figure 2). 



Anthropological analysis of the skel- 
etal material showed those specific de- 
structive and erosive changes known to 
be caused by Mycobacterium leprae in 
the hands, feet and lower extremities. 
Evidence of tuberculosis, in the form of 
pleural calcification, was also noted in 
this collection (Figure 3). 

The appearance of tuberculosis and 
leprosy, both of which are rare in the 
Holy Land, raises important questions 
about this site. Although hospitals were 
frequently associated with monas- 
teries, no literary evidence from this 
period attests to the existence of a hos- 
pital at the Monastery of Saint John. 
However, the high incidence of patho- 
logical material found here suggests 
that these buried here were seriously 
ill, perhaps members of a hospital pop- 
ulation who may have been banished to 
the desert. This tradition of banishment 
is apparently an ancient one, in that the 
first archeological evidence of leprosy 
comes from the Dakleh oasis in the 
Egyptian desert. Here, interred in a 
Sudanese cemetery dated to about 200 
B.C., were the remains of four Cauca- 
sian males, all of whom showed stig- 
mata of leprosy (Dzierzykray-Rogalski 
1980). 

Further survey and research in the Ju- 
dean Desert monasteries, which pre- 
date the Danish leprosaria by some 600 
years, should provide an answer to the 
much-debated question of which dis- 
eases in antiquity were included in the 
generic category leprosy. For example, 
talmudic evidence of the postbiblical 
and Byzantine periods suggests that se- 
vere nasal disfigurement was con- 
sidered one of the stigmata of leprosy 
(Rosen 1982); at this site, 2 of the 34 
skeletons showed nasal abnormalities 
characteristic of neither tuberculosis 
nor leprosy. The cotton textiles re- 
covered from this site may also shed 
light on whether those buried here, ap- 
parently seriously ill and banished to 
the desert, had been required to wear 
distinctive clothing indicative of their 
health status. 

Finally, one of the more intriguing 
medical questions that may be an- 
swered by further study of these monas- 

Atfirfh l*aleopatholof>\ Sytnp. 19HH 



Leprosy and tuberculosis in Byzantine monasteries of Judea • 199 






i 



Figure 3. Calcified pleura. (Courtesy of Israel Department of Antiquities and 
Museums — T. Sagiv) 



tic sites is that of the paleoepidemiolo- 
gy of leprosy and tuberculosis. Since, 
apart from this find, tuberculosis and 
leprosy have rarely been found in the 
Holy Land, these patients may have 
come from abroad or may have immi- 
grated while incubating these diseases. 
One wonders, therefore, what factors 
may have operated to restrict the dis- 
eases to these desert communities. Was 
social and religious separation between 
the various communities so complete as 
to protect the members of one com- 
munity from a disease prevalent in an- 



other? Did those who traveled great dis- 
tances do so for spiritual reasons, or 
had they been banished from their home 
communities? According to Judaic 
and Christian literary sources of that 
period, those suffering from these dis- 
eases were ostracized. Perhaps they 
were welcomed by these desert com- 
munities, thus explaining the lack of 
such remains elsewhere in the Holy 
Land. Further excavations and other 
studies in the monasteries of the Judean 
Desert may well provide answers to 
questions such as those raised here. 



Literature cited 

Avi-Yona, M. 1963. The Bath of the Lepers 
at Scythopolis. Israel Exploration Jour- 
nal. 13:325-326. 

Browne, S. 1975. Some Aspects of the His- 
tory of Leprosy: The Leprosy of Yester- 
day. Proceedings of the Royal Society of 
Medicine. 68. 

Dzicrzykray-Rogalski, T. 1980. Paleo- 
pathology of the Ptolemaic Inhabitants of 
Dakleh Oasis (Egypt). Journal of Human 
Evolution. 9:71-74. 

Hoade, E. 1981. Guide to the Holy Land. 
501-504. Jerusalem: Franciscan Press. 

Preuss, J. 1978. Biblical and Talmudic 
Medicine. New York and London: San- 
hedrin Press. 

Rosen, Z. 1982. The Healthy and the Dis- 
eased Nose in the Bible. Proceedings of 
the First International Symposium on 
Medicine in the Bible. Koroth. 8:79-85. 

Smith, G.E., and W.R. Dawson. 1924. 
Egyptian Mummies. London: Allen and 
Unwin. 

Zias, J. 1985. Leprosy in the Byzantine 
Monasteries of the Judean Desert. 
Koroth. 9:242-248. 

Summary of audience discussion: The 
lesions on the anterior surface of the patella 
arc considered occupational (monastery 
monk) because of their ancient and even 
modem habit of falling to their knees, ris- 
ing, then kneeling again and continuing this 
process daily for hours on end. Since, dur- 
ing kneeling, the patella does not actually 
make contact with ihe ground, but suffers 
substantial stress during the lowering and 
raising of the body, the lesions may result 
from that stress. We also found lice, not so 
easily in the mummy's hair but very easily 
in the hair combs. 



Zanreh Pateopathoiogy Symp. 1988 



Evidence of disease in ancient 

Near Eastern texts: Leprosy in the 

Epilogue to the Code of Hammurapi? 

Debra A. Chase 



A great deal of caution must be exercised in the discussion 
of disease in ancient Mesopotamia. In part, this caution is 
due to the nature of the available sources which, scattered 
over many centuries, are often fragmentary and filled with 
lexical difficulties. ' It is the duty of the philologist and stu- 
dent of the culture to interpret texts using etymologies, and 
literary and form critical analyses. This textual work is not 
complete, however, without input from the physical and so- 
cial sciences (Biggs 1969:103). Over a quarter of a century 
ago Oppenheim (1962:107) noted that the study of Meso- 
potamian medicine had been hampered by separation be- 
tween departments: its interpreters were "either philologists 
lacking knowledge of medicine, its history, or that of phar- 
macology, or physicians without adequate linguistic train- 
ing." It is in the spirit of long-needed interdisciplinary 
cooperation that I off"er for discussion this text from the Epi- 
logue to the Code of Hammurapi, which, I believe, presents a 
more complete picture of the clinical manifestations of lep- 
rosy than any other text from ancient Mesopotamia proposed 
to date. 2 

Before examination of the passage let me give a brief 
synopsis of the use of the term in the translations of textual 
data from Mesopotamia. In my study I have encountered at 
least four different words that have been translated by "lep- 
rosy." There is a fairly straightforward philological explana- 
tion for this: the Akkadian loanword saharsuppu may be 
traced to Sumerian SAHAR.SUB.A.. literally, "covered with 
dusf (i.e., dustlike, whitish scales) (Oppenheim 1956: 
273n.54). Indifferent lexical series 5-4/M/?.5t/S./4. is equa- 
ted with the terms epqu and gardbu. Thus, saharsuppu = 
epqu = gardbu. Furthermore, .ra^wrv(//7^M occurs in contexts 
in which the affliction covers the individual "like a garment" 
and results in his wandering outside the city walls "like a wild 
ass on the steppe." The combination of excommunication 
and "whitish scaly skin" — which was not considered inap- 
propriate for leprosy until Dr. S.G. Browne (1967:190) 
pointed out its unsuitability in a reply to J. V. Kinnier Wilson 



(1966:47-58) — contributed to the translation of the Akka- 
dian as "leprosy." The fourth term, busdnu, seems to have 
been translated "leprosy" on the basis of association with 
symptoms more appropriate to the disease (it atTects the 
mouth, nose, skin); however, other references would militate 
against such a diagnosis. 

It is necessary to underscore that the passage from the 
Epilogue is not a medical text. It does not set forward symp- 
toms for the sake of diagnosis or prescription of medication. 
Rather, it is a single curse invoking the goddess Ninkarak, in 
the context of a series of curses which Hammurapi enjoins 
the gods to bring upon those who would in some way change 
his laws. The form — (1) deity name (2) deity epithet (3) 
curse — is typical of Near Eastern curses for a period of more 
than a millennium. The diction and poetic devices apparent 
in the curse reveal a subtle literary skill. I would suggest, 
however, that behind the imagery lies a very specific disease 
entity that Ninkarak is called upon to inflict. Such a supposi- 
tion is supported by the fact that the basic nature of the curse 
remains the same over time. Although the description of the 
symptoms is general by modem standards and certainly not 
pathognomonic, the presence of cutaneous lesions, testicular 
damage, and suggestion of neuropathy point to a considera- 
tion of leprosy as the disease. 

The text and translation follow:^ 

50. ^Ninkarak 

51. marat Anim 

52. qabiat 

53. dumqiya 

54. ina Ekur 

55. mursam kabtam 

56. asakkam lemnam 

57. simmam marsam 

58. Sa la ipaSSehu 

59. asO qerebSu 

60. la ilammadu 



200 



Zagreb Paleopathology Symp. 1 988 



Leprosy in the Epilogue to the Code of Hammurapi? • 201 



60. 


la ilammadu 


61. 


ina simdi 


62. 


la unahhuSu 


63. 


kima ni.sik mutim la innassahu 


64. 


ina binlatT^u 


65. 


li$asia.<S$umma 


66. 


adi napiStaSu 


67. 


ibellu 


68. 


ana etIutlSu 


69. 


liddammam 



50. May Ninkarak, 

51. the daughter of Anum, 

52. who speaks 

53. my well-being 

54. in Ekur, 

65. cause to break out 
64. on his limbs, 

55. a serious illness, 

56. an evil affliction, 

57. a grievous sore 

58. which does not heal, 

59. whose nature the doctor 

60. cannot find out, 

62. which he cannot soothe 

61. with bandages, 

63. (which) like the bite of death cannot be removed, 

66. so that until his life 

67. is extinguished, 

69. he keeps on moaning 

68. about his virility. 

The translation of the curse is straightforward and presents 
few difficulties for the philologist. In lines 50-54 Ninkarak is 
identified as the malefactor. Ninkarak, equated with Gula 
and Nin-Isina, all healing goddesses,'* is the daughter of 
Anum, the supreme god of heaven. She is the great physi- 
cian, azugallalu rabitu,^ who confers life and revives from 
death. ^ Her role as a divine healer makes her eminently suita- 
ble as the perpetrator of an incurable affliction and she is 
frequently summoned for this role in the cur.se formulae of 
certain inscriptions.^ The curse, set forward in lines 55-69, 
details the nature of the disease. The discussion that follows 
includes comments on the range of meaning of the Akkadian 
diction, together with brief literary critical notes, and the 
signs and symptoms of leprosy that appear in the text. 

Leprosy is a chronic infection caused by Mycobacterium 
leprae which primarily attacks the peripheral nerves and der- 
mis.** The clinical manifestations vary widely depending 
upon the immunological response of the host. Variations of 
the disease range from tuberculoid leprosy to lepromatous 
leprosy. Specific diagnostic criteria have been established for 
these forms, although most individuals will present some- 
where along the spectrum between the two poles. Knowledge 
of the clinical aspects of leprosy provides data relevant to an 
understanding of Ninkarak's curse. 



Line 55: mur^am kabtam "a serious illness," literally, "heavy 
illness." mursii is used generally of physical ailments and 
with a qualifier (often part of the body) for specific illnesses 
(CAD M/2 224-227).9 

Line 56: asakkam lemnam "an evil (in the sense of "danger- 
ous," "bad") affliction." According to CAD All 'ilS-'ill, 
asakku is both a demon and the diseases it causes. As 
Ninkarak is the subject, the one inflicting the ailment, it is 
clear that another personality is not involved; but the nature 
of the ailment (other than evil) cannot be further specified. 
The figurative aspect of the description is underscored by the 
fact that the term is not found in medical texts (CAD All 
326b). It is noteworthy that Jacobsen (1946:147) interpreted 
the Sumerian A-sag literally as "the one who smites the arm." 
Although it has been suggested that this interpretation is 
"probably a popular etymology" (CAD All 326b), the asso- 
ciation with binding, laming, crippling, or paralysis is partic- 
ularly suggestive with respect to the diagnosis of leproma- 
tous leprosy in which, in the advanced stage, "peripheral 
nerve disease leads to widespread neuropathic deformities" 
(Stein et al. 1983:1423).'° A more secure reference in this 
context is the mention of miqtu "incurable paralyzation (?)" 
that is attributed to Gula in a similar curse. ' ' 

Without treatment "fibrosis of nerves is an inevitable end- 
result of lepromatous leprosy . . . causing bilateral 'glove 
and stocking' anaesthesia" (Jopling 1984:17). Edema of the 
legs, an early symptom of lepromatous leprosy, might be 
applicable here, but the parallel reference to miqiu would 
suggest a more serious disease process. Furthermore, such 
edema usually precedes the classical skin lesions (Jopling 
1984: 19), and in this text, emphasis is clearly placed on skin 
changes. Because of this emphasis, I am inclined to suggest 
that the text portrays lepromatous leprosy in which the physi- 
cal signs in the skin are likely to be noticed first and evidence 
of damage to nerves occurs late (Jopling 1984:21).'- 

Line 57: simmam marsam "serious (grievous) sore/skin erup- 
tion." The synonymous parallelism of these three lines poet- 
ically emphasizes the severity of the malady." The final 
description, simmam marsam. provides the most diagnostic 
information. 

There are many types of simmu: The deities Sin and Enlil 
are described as putting every kind of simmu in the land 
(AA/r84,4 ii 9 and 1 1 cited from CAD S 277b-278a). Fbrthe 
most part, simmu appears to be associated with the skin (also 
eye) where it may break out (wasii), appear (basu). or heal 
(baldtu) (GIG as simmu). It may be infectious (ARM 10 
130:3,14), and it may be treated with medications or ban- 
dages (CAD S 276-278). '•* 

In this passage from the epilogue Ninkarak is called upon 
to "bring out" the simmu. cause it to "come forth," (perhaps 
"erupt") (S of wa.)u, line 65) on the limbs of the offender. 
Note that the skin lesions of lepromatous leprosy present a 



Zagreb Paleopathology Symp. 1988 



202 • Debra A. Chase 



"most variegated clinical spectrum" (Arnold and Fasal 
1973:40). The skin manifestations may be "macules, pa- 
pules, nodules or all three" (Jopling 1984:20). They are mul- 
tiple with bilateral symmetrical distribution. The face, arms, 
buttocks and legs are principally involved. '^ 

The malady is further qualified by the relative clause be- 
ginning in line 58 in which the reader is told: (1) that the 
illness does not heal (with the denotation of "calm down." 
"be appeased") (line 58), (2) that the doctor cannot find out 
its fundamental nature (qerbiim) (lines 59-60), and (3) that it 
is not relieved with bandages (denotation of nc'ihu = abate- 
ment of illness (CAD N/1 147a]; D of /id/jw "to stanch, still, 
allay" ICADN/1 149a)) (lines 60-61). The verbs pwid^M and 
ndhii may suggest inflammation and perhaps pain (as does 
the adjective marsam in line 57). I would suggest that if pain 
is implied the text associates it with the skin lesions. In this 
context it is significant that, particularly in the reactional 
states of leprosy, there may be a fairly rapid change in skin 
lesions. Note especially, in a severe Type 2 reaction, which 
occurs almost exclusively in lepromatous leprosy, the lesions 
become vesicular or bullous and break down (erythema nec- 
roticans) (Jopling 1984:72 and plate 19). Fever, nerve pain, 
periosteal pain, muscle pain, and joint pain may also occur 
(Jopling 1984:73). The neuritis associated with leprosy 
would be a source of pain; however, in one study 81% of 
patients gave no significant history of pain or tenderness in 
affected nerves (Fritschi 1987:173). Again note that unlike 
tuberculoid leprosy, where pain may be present from the 
earliest stages of the disease, in lepromatous leprosy, nerve 
damage usually occurs late. 

The striking simile in line 63 underscores the victim's 
helplessness, the futility of any efforts to overcome the ail- 
ment: kima nisik mutim Id iimassahul "like the bite of death it 
cannot be removed.''^ The image is palpable; the simmu. 
asakku. miirsu is apparent on the offender's arms and legs, a 
constant reminderof impending death, specified in lines 66- 
67: adi napistasu ihellii/ "until his life is extinguished." 

Line 68: ana etlutisu Uddammam. The verb damdmu here 
means "to moan, mourn." There is some debate over the 
translation oi etlutisu. An etlu is a man, particularly a young, 
able-bodied man (CAD E 407). The form in line 68 may be 
interpreted as the nominative plural "men" and as such, the 
passage has been translated "he will complain to his men" 
(CAD E 409b; see also B 73a, D 60a). Such a translation, 
however, is ill suited to the context. There is no previous 
reference to the afflicted one's interactions with others and 
certainly no meaningful referent for "his men." In light of the 
context of affliction and general physical degradation, it is 
preferable to read etiutu. "virility';''' thus, "may he con- 
tinually moan about his virility." Such a reading is congruent 
with the tangible imagery of the curse and, as the final blow, 
acutely conveys the humiliation of the progressive debilita- 
tion. 



The image here is certainly of physical breakdown; how- 
ever, the reference may even be more specific and refer to 
testicular atrophy. "Testicular involvement leading to impo- 
tence, sterility and gynecomastia is well documented in lep- 
romatous leprosy" (Pareek and Al-Nozha 1985:49). "* "Vary- 
ing degrees of testicular atrophy are likely to occur, 
particularly if the disease is neglected" (Jopling 1984:31). In 
the earlier stages the individual is sexually potent but sterile. 
Impotence and gynecomastia are later developments. Also in 
Type 2 reaction the testes may become swollen and tender 
with acute epididymo-orchitis (Jopling 1984:73).''' 

Although not diagnostically conclusive, the symptoms 
may be interpreted as representative of lepromatous leprosy. 
Clearly, a chronic skin disease involving numerous skin 
lesions — specifically located on the arms and legs — is de- 
scribed. The severity of the ailment is reinforced by the re- 
petitive formulation of lines 55-57, the fact that its etiology 
is unknown by the medical practitioner (as well as the fact 
that it is inflicted by the "divine" doctor), and that surface 
treatments are of no avail (Fritschi 1987:173).-'' There is an 
implication that the disease is progressive in the simile, line 
63, and more concretely, in the iterative verb form (Uddam- 
mam Gtn damdmu) "he keeps on moaning (line 69) until his 
life is extinguished" which points to a length of time between 
recognition of the infection and its conclusion.-' The possi- 
bility of peripheral nerve involvement, common in advanced 
lepromatous disease, was alluded to previously. Although 
little diagnostic emphasis can be placed on asakku in our text, 
it is intriguing that the malady miqtu. from the root maqdtu 
"to fall down," is associated with the goddess's persistent 
simmu in another text.-- Finally, the reference to the loss of 
virility (lines 68-69) may be interpreted as the testicular 
damage that leads to atrophy characteristic of lepromatous 
leprosy. 



End notes 

1 . A number of summaries on medicine in ancient Mesopotamia 
are available: Labat 1953; Oppenheini 1962; Reiner 1964; Biggs 
1969,1978. 

2. The most current proposal of which I am aware is that of 
Kinnier Wilson (1982:354-357) who suggests that in an Old 
Babylonian omen text published by Kocher and Oppenheim in 
1957, \\\epusu "white spots." and niuidu perhaps, "nodules." on the 
aftlicted man be interpreted as dimorphous leprosy. Although I 
cannot offer another interpretation of the skin marks, it seems to 
push the data too far to infer leprosy without further descriptive 
material. 

3. Codex Hammurabi Epilogus R XXVllI .^-69 (Tafel 29). 
Tablet and line numbers arc taken from the edition of Borger( 1963). 
The normalizations and translations of the text are my own. 

4. See Haussig 1965:78 and Wcidner and von Sodcn 1971:695. 

5. See. for example, this epithet in the parallel curses: Borger 
1970 (Kudunm SB kol. IV 5-6). 1967:109 (IV 3); King 1912:7 ii 
29-31. 



Zagreb Paleopathology Symp. 1988 



Leprosy in the Epilogue to tiie Code of Hammurapi? • 203 



6. RLA 3 695. Note the hymn of Nebuchadnezzar to Ninkarak in 
which Nebuchadnezzar appeals to her as a health goddess — for his 
own health and longevity and that of his children and descendants 
(von Soden and Falkcnstcin 1953:#33). 

7. See Kudurru (boundary stone) of MeliSihu VII 14-25 (Scheil 
19(X): 1 10); Kudurru SB 33 IV 5-9 (Borger 1970); King 1912; no. 8 
IV 16. 1 R 70iv6andp.4l 7 ii 29-31 and p. 79 11 iii 10-13. 

8. R)r an introduction to the subject see Braunwald et al. 1987; 
du Vivier 1986; Fitzpatrick et al. 1987; Jopling 1984; Stein et al. 
1983. 

9. R)r example, associated with the goddess Gula but with re- 
gard to the heart: GIG Id pcidu ami lihhisu lifhsiC.') KAR 111 r.8 
cited from CAD M/2 226a)/ "May (Gula bring) an illness without 
pity into his heart." 

10. "A diffuse hypesthesia involving the peripheral portion of 
the extremities is common in advanced leproiiiatous disease" 
(Braunwald etal. 1987:635). 

1 1 . Kudurru SB 33 IV 7 which Borger translates as "unheilbare 
LahmungC?)" ( 1970; 15). See also Goctze ( 1955; 12) who notes that 
miqtii, literally "fall." is used of attacks for various sicknesses and 
sometimes equated with bennu. "epilepsy." 

12. Here Jopling clarifies that "nerve damage in lepromatous 
leprosy ... is different from the pathological process in the other 
types of leprosy and is much slower to unfold." While in borderline 
leprosy "clinical evidence of nerve damage, whether sensory or 
motor, or both, is likely to antedate skin lesions by months or years" 
( 1984; 15). Tuberculoid leprosy patients may present with neural or 
dermal symptoms or both (1984:34). 

13. Note the alliteration (particularly m. s, s, and k) and the 
inelusio and wordplay, mursiim-nuirsam. 

14. The range of meaning of Akkadian simmum has been com- 
pared to Greek elkos which embraces both notions of wound and 
ulcer. (Stol 1979:62 n.232. kindly brought to my attention by Pro- 
fessor W.L. Moran). 

15. Sec Jopling 1984:rigs. 4.15.18, erythema nodosum lep- 
rosum in Type 2 reaction-which occurs almost exclusively in lep- 
romatous leprosy or may be the stage at the patient's presentation 
(1984:70). 

16. The image here has several levels; (1) Death is frequently 
anthropomorphized as a maw; consequently, the image would be 
particularly vivid for its indigenous readers/hearers. See also ina 
sinnatisu izdb mutumi "from his (the demon's) teeth flows death." 
(A 704: 16 cited from CAD M/2 318a). (2) The symbolic animal of 
Gula is the dog. (3) Familiarity with an actual animal bite introduces 
the elements of the unexpected and speed — a bite often cannot be 
anticipated or prevented — thus heightening the sense of anxiety. (4) 
The physical image; once the flesh has been pierced, although the 
teeth may be removed, the evidence of the attack cannot — thus, the 
omnipresent awareness of injury. 

17. CAD E 41 lb. Von Soden (1965:1 266a) who quotes this 
passage under etlutu. defines the word as "Mannheit." Therefore, 
our form <v/m/("v(/ = genitive of <'(/«/« + 3ms suffix. 

18. This study notes earlier reports stating that half of the males 
with lepromatous leprosy develop testicular atrophy. 

19. Note as well that protein and red blood cells occur in the 
urine. In this context it is most interesting to compare a difficult 
passage in a parallel curse associated with CJula's persistent \immu: 
surka u diimci/kimti me lirhimmiik. "so that he may pass light anil 
dark blood like water ' (King 1912:7 ii 31; 11 iii 12-13). 



20. It is significant that in four other texts Gula is associated with 
this same incurable affliction — \immt4 lazzti. "a persistent sore/skin 
eruption" (Scheil 1900;I10|VII 19|;King 1912:41 1 7 ii 30]; Borger 
1 967 ; 1 09 1 1 V 4 1 ); and simma aLfii lazza, "a terrible . persistent sore" 
(Borger 1970;I5 |IV 6|). 

21. "The course of untreated lepromatous leprosy in presulfone 
days was in general a progressive downhill one. with eventual fatal 
termination. . . . The disease itself is seldom a direct cause of 
death, ... but it .so enfeebles the patient in advanced eases that 
other infections may have a fatal outcome" (Arnold and Fasal 
1973:51-52). 

22. See note 1 1 . 

Literature cited 

Works frequently cited have been identified by the following ab- 
breviations; 

AMT R.C. Thompson. Assyrian Medical Texts. Oxford 

1923. 
ARM Archives royales de Mari. Paris 1950ff. 
CAD The Assyrian Dictionary of the Oriental Institute of the 

University of Chicago. Chicago 1956ff. 
RLA E. Ebeling and B. Meissner, cds. Realle.xikon der as- 
.nriologie. Berlin I928ff. 

Arnold, H.L., and P. Fasal. 1973. Leprosy Diagnosis and Manage- 
ment. Springfield, III.; Charles C Thomas. 

Biggs, R. 1969. Medicine in Ancient Mesopotamia. History of 
Science. 8:94-105. 

1978. Babylonien. In H. Schipperges, E. Seidler, P.U. 

Unschuld, eds., Krankheit, Heilkunst, Heilung, 91-114, 
Munich: Verlag Karl Alber. 

Borger, R. 1963. Bahylonisch-Assyrische Lesestiicke. Ill Kommen- 
tar die Texte in Keilschrift. Rome; Pontifical Biblical Institute. 

1967. Die Inschriften Asarhaddons Konigs von Assyrien. 

Osnabrijck, Germany; Biblio Verlag. 

_. 1970. Vier Grenzsteinurkunden Merodachbaladans I. von 



Babylonien. Archiv fiir Orientforschung. 23:15 (Kudurru SB 33 
kol.IV5-6). 

Braunwald, E., K.J. Isselbacher. R.G. Pctcrsdorf J.D. Wilson, 
J.B. Martin, and A.S. Fauci, eds. 1987. Harrison' s Principles of 
Internal Medicine. New York: McGraw-Hill. 

Fitzpatrick. T.B.. A.Z. Eisen. K. Wolff. I.M. Frecdberg. and K.F. 
Austen, eds. 1987. Dermatology in General Medicine. New 
York: McGraw-Hill. 

Fritschi, E.P. 1987. Field Detection of Early Neuritis in Leprosy. 
Leprosy Review. 58(1-3): 173-77. 

Goetze. A. 1955. An Incantation Against Diseases. Journal of 
Cuneiform Studies. 9:8-18. 

Haussig. H.W.,ed. 1965. Worterbuch der Mythologie I Gotter und 
Mythen im Vorderen Orient. Stuttgart, Germany; Ernst Klett Ver- 
lag. 

Jacobscn. T. 1946. Sumerian Mythology: A Review Article. Jour- 
nal of Near liaslern Studies. 5: 1 28- 1 52. 

Jopling. W.H. 1984. Handbook of Leprosy. London: Heinemann 
Medical Books. 

King. L.W. \')\2. Babylonian Boundary Stones. London. 

Kinnier Wilson. J.V. 1966 Leprosy in Ancient Mesopotamia. Re- 
vue d'Assyrudogie. 60:47-58. 



Zagivb Paleopathology Symp. 1988 



204 • Debra A. Chase 



1982. Medicine in the Land and Times of the Old Testa- 
ment. In T. Ishida. ed.. Studies in the Period of David and Sol- 
omon and Other Essays. 337-365. Winona Lake, Ind.; 
Eisenbrauns. 

Labat, R. 1953. La Medecine Babyloniennc. In Les Conferences 
faile au Palais de la Decouverie le IS Avril 1953, 5-23. Paris: 
Universite de Paris. 

Oppcnhcim, A.L. 1956. The Assyrian Dream-Book. Philadelphia: 
American Philosophical Society. 

1962. Mesopotamian Medicine. Bulletin of the History of 

Medicine. 35(2):97-108. 

Pareek, S.S., and M. Al-Nozha. 1985. Mycobacterium leprae in 
Seminal Fluid: A Case Report. Leprosy Review. 56:49-50. 

Reiner, E. 1964. Medicine in Ancient Mesopotamia. Journal of the 
International College of Surgeons, 41:544-550. 

Scheil, V. 1900. Delegation en Perse Memoires. II Textes Elamites 
Semitiques. Paris: Leroux. 

von Soden, W. 1965-1981. Akkadisches Handworterbuch I-III. 
Wiesbaden, Germany: Harrassowitz. (1, 1965; II, 1972; 111, 
1981.) 

von Soden, W., and A. Falkenstein. 1953. Sumerische und Ak- 
kadische Hymnen und Gebete. Zurich: Artemis. 

Stein, J.H., M.J. Cline, W.J. Daly. J.D. Easton, J.J. Hutton. P.O. 
Kohler, R.A. O'Rourke, M.A. Sande, J.S. Trier, and N.J. 



Zvaifler, eds. 1983. Internal Medicine, vol. 2. Boston: Little, 

Brown, and Co. 
Stol, M. 1979. On Trees. Mountains and Millstones in the Ancient 

Near East. Leiden, Netherlands: Ex Oriente Lux. 
du Vivier, A. 1986. Atlas of Clinical Dermatology. Philadelphia: 

W.B. Saunders. Weidner, E., and W. von Soden, eds. 1971. 

Reallexikon der Assyriologie und Vorderasiatischen Archaologie 

3. Berlin: de Gruyter. 



Summary of audience discussion: Because people write about 
what is important to them, texts may be a useful source of informa- 
tion regarding disease in past periods even if the purpose of the text 
is nonmedical. If the described condition is really leprosy, the tex- 
tual emphasis on peripheral, dermatological involvement is surpris- 
ing. The fact that skin changes occur early appears to be an inade- 
quate explanation since the comment regarding virility suggests 
testicular involvement which occurs much later. Another limitation 
is the fact that this manuscript is obviously a curse, and therefore 
should not be expected to be a precise description of a disease. An 
acute, lethal disease involving predominantly skin may be more 
likely. A recent translation of the Egyptian Ebers Papyrus does not 
mention lepromatous leprosy. 



Zagreb Paleopathology Symp. 1988 



The medieval diagnosis of leprosy 



Jobs G. Andersen 



Modern clinical diagnosis 

In clinical praxis the diagnosis of leprosy rests on the pres- 
ence of at least two or three symptoms: hypopigmented skin 
lesions, reduction or loss of sensation in visible skin lesions, 
and enlarged peripheral nerves. Demonstration of alcohol- 
and acid-fast, intracellular rods in slit skin smears or biopsies 
confirms the diagnosis unequivocally. 

Classification 

In the classical texts no attempts at classification are met. The 
medieval literature abounds in terms that show a characteris- 
tic emphasis on individual, significant symptoms. The texts 
obviously presume a direct teacher-student situation. 

The described symptoms fit effortlessly into a description 
of borderline lepromatous leprosy. As typical of this we can 
refer to the famous Flos Medicina from the medical school in 
Salerno (de Gaddesen 1492): 

De Specibus Leprae 

Tyria primo datur de flegmate qua generator, 

Inde leonina cholera generante ferina 

Triste pilos tollens allopicia sanguine nascens, 

De mclancolia tristis elephancia sacvior istis. 

In facie noli tangere, in partibus herpes, 

Inferius si sit dicitur esse lupus. 

Or in translation: 

Tyria in the beginning originates only from mucus 
Wild is leo, and comes to our sorrow from t"gall of the 

body 
Bom from bad blood and extracting the hair is the sad 

alopecia 
Elephas. still more wild, it is bom from the sorrowful black 

gall 
When it is seen in the face and breaks out in the skin, it is 

hopeless 
Lupus we call it when only the parts further down are 

attacked. 



The first attempts at a classification that approaches our 
understanding appear toward the end of the 19th century. 
Here also for the first time we meet descriptions that can refer 
to tuberculoid leprosy. 

As typical examples we can refer to the classifications as 
described by Danielsen (1873) or Borthen and Lie (1899). 

During the first half of the 20th century most practicing 
leprologists classified leprosy as lepromatous or non- 
lepromatous leprosy. Ridley and Jopling in 1966 introduced 
the now universally accepted five-point classification, based 
on the immunological response of the host. In 1969 I intro- 
duced the terms "high resistance leprosy" (HRL) and "low 
resistance leprosy" (LRL). They provide a reasonably accu- 
rate relation to the immunological classification. Since the 
introduction of multidrug therapy (WHO Study Group, 
1982) there is a tendency to classify leprosy as multibacillary 
or paucibacillary leprosy for purposes of primary drug thera- 
py. Unfortunately there is no generally accepted definition of 
these terms. The reader is referred to Figure 1 for comparison 
between the different classifications. 



Reading of ancient texts 

The free use of quotations, frequently without any acknowl- 
edgment of source, makes it difficult to assess which is an 
original observation, and which is a reference to existing 
knowledge. There is a tendency to describe symptoms, with 
less correlation of different symptoms to define a particular 
disease. It can be difficult to determine if a particular term 
covers a subgroup of a given disease or rather a disease in 
itself. We should not overlook the confusing use of the terms 
derived from elephas and lepra, indicating the same disease. 
Direct translations can cause misunderstandings: The 
Greek p«M,v and <7j<'/V, usually translated as /laW and/oof. are 
frequently used to indicate the whole extremity. The same is 
true about the Latin pes and manus. Extremitas manus can 
thus mean either the upper extremity or the distal part of the 
hand, that is, the tips of the digits. 



Zagreb Paleopathology Symp. 1988 



205 



206 • Jobs G. Andersen 



TT BT BB BL LL 


Ridley arxj 
Jopling 


High resistarx;e 
leprosy 


Low resistance leprosy 


Andersen 


Paucibacillary 
leprosy 


Multibacillary leprosy 


WHO 


Non-lepromatous 
leprosy 


Lepromatous leprosy 


Earlier 
leprologists 




Maculo-anaesthetic 
leprosy 


Lepra tuberosa 


Borthen and Lie 




Lepra 
anaesthetica 


Lepra 
tuberculosa 


Danieisen 



Figure 1 . The relationship between different classifications of leprosy. 



Classical texts 

Unfortunately the earliest literary reference to leprosy in the 
Mediterranean world has been lost. We know it only from a 
quotation in the works of Oribasius (a.d. 326-403). He men- 
tions that Straton, famulus of Erasistratos from Keos (300- 
250 B.C.) describes elephas as a new disease. It is not clear 
how much of Oribasius's description is attributed to Straton, 
and how much represents his own observations. In any event 
the nodules, ecchymosis-like skin lesions, and the nonheal- 
ing ulcers definitely point toward LRL. The picture is more 
appropriate to leprosy in light-skinned races. This may be 
confusing to leprologists who are accustomed to dealing with 
dark-skinned races. 

Albinovarus Cornelius Celsus (25 b.c.-a.d. 37) mentions 
leprosy as a relatively new disease in Italy. He writes a re- 
markably lucid, beautiful Latin, which leaves no doubt that 
he describes LRL: "Crebri tumores" exactly fits the appear- 
ance of partly confluent, nodular infiltration. "Summa cutis 
indaequaliter crassa, tenuis, dura, mollisque, quasi squamis 
exasperatur" reads as a description of borderline lepromatous 
leprosy with the characteristic, irregular, ring lesions with a 
flat center, pseudopodia-like spread, and a shift to the lep- 
romatous side with widespread macules. "Digiti in manibus 
pedibusque sub tumore conduntur" recalls the patients with 



partial digital absorption and swelling of hands and feet due 
to reversal reaction. "Ossa quoque vitiari dicantur" could be 
a reference to peripheral absorption or to ulcer-induced bone 
destruction. In any case it fits very well into the whole pic- 
ture. 

Caius Publius II Plinius (a.d. 23-79) is a typical poly- 
historian who writes extensively about everything. He is not 
a medical man. The main interest in his writings is the fact 
that he specifically mentions that leprosy was unknown in 
Italy prior to the return of Gnaeus Pompeius Magnus (106- 
48 B.C.) from the Pontine campaign in 62 B.C. 

Aretaios Kappadox (ca. a.d. 200) is without doubt the 
most lucid and informative of the authors from this period. A 
number of interesting points can be gleaned from his writ- 
ings: Elephas (i.e., leprosy) is also known as leo. This pre- 
sumably refers to facial infiltration. He is aware of the insid- 
ious beginning of the disease, and mentions that foul- 
smelling respiration is characteristic. "Tumors of the body" 
easily reads as "nodular infiltration." Hoarse voice and loss 
of hair arc characteristic symptoms. Leprous alopecia geo- 
graphica is extremely rare in dark-skinned races, but fairly 
common in advanced borderline lepromatous or lepromatous 
leprosy in light-skinned races. 

As a surgeon I am particularly intrigued by the first men- 
tion of plantar cracks and ulcers. The expression "loss of 



Zagreb Paleopalbotogy Symp. I9RH 



The medieval diagnosis of leprosy • 207 



nose" may well refer to the contracted/collapsed nose that is 
so common in advanced, borderline, lepromatous leprosy 
and lepromatous leprosy. All in all a modem leprologist has 
little to add to his description of LRL. 

It is remarkable that the famous physician, Claudius 
Galenos (a.d. 130-201), who has been held in such high 
regard through the ages, should fail to add to previous knowl- 
edge. 

Medieval texts 

When we move on to the medieval writers we must remem- 
ber that their knowledge of the classical literature came from 
translations of the original Greek and Latin into Arabic and 
retranslations into Latin. From this time until the end of the 
lyth century, the terms lepra and elephas (and derivatives) 
are used alternately to describe the same disease. The confu- 
sion with biblical "leprosy" is a later phenomenon. 

One is frequently struck by the simple mention of what is 
obviously intended as a description, but without the defini- 
tion and explanation that we expect from a medical text. It 
probably means that the text is intended as a vade mecum, 
while the detailed teaching is presumed from a direct teacher- 
student relationship. The teaching hexameters in Flos Medic- 
ina (de Gaddesen 1492) provide good examples: 

De Signis Variarum Specierum Leprae 
Candescit cutis in tyria, mollescit et albet. 
Nee membris lymphae profusio facta cohacret, 
Signa leoninae: manuum fissuraque pedum, 
Aspcra rupta cutis, macies, pruritus et ardor. 
Vox est rauca, color citrinus, mobile lumen. 
Fit gingivarum corrosio, naris acuta 
contrahit et spasmat, species elephancia nervos, 
corrugat naris, oculos facit esse rotundos, 
tubera dura rigent, caro livida, sqalidus unguis 

Or in translation: 

When the skin pales and is blotched, it is taken as symptom 

of tyria. 
Then there is no longer lymph to be found in abundance in 

the members, 
Leo you know from the cracks which are found in the 

hands and the feet. 
Also in them you find broken skin, leanness and itching 

and buming. 
Hoarse voice and a face with the color of lemon, and eyes 

which are roving. 
Gums which are eaten away, while the nostrils arc pinched 

and obstmcted. 

Amaldusde Vila Nova (a.d. 1235-1312) is a typical propo- 
nent of medieval knowledge of leprosy, from De Signis Lep- 

rosorum Libcllus we glean: 



Si vox rauca est, forte signum est leprae [laryngeal infiltra- 
tion] 

In superciliis oculorum leprosi non habet pilos maxime 
apud angulos |madarosis| 

Supercilia habent quandam rotunditatem, qua videntur 
quasi spherica et rotunda (lagophthalmos with re- 
tracted eyelids] 

Oculi videntur quasi exire locum eorum |lagophthalmos 
with pscudocxophthalmos] 

Facies — habet aspectum niultum terribilem [lagophthalmos 
and /or facial infiltration] 

Leprosi cognascuntur ex vulnere existente in naribus Jendo- 
nasal ulceration] — excoriatio in profunditate nasi [in 
contradistinction to e.g. scrofulosis]. 

He even has an excellent description of how to examine for 
loss of sensation: 

Item facias ipsum cooperiri ne videat et sibi die: cave quod 
ego te pungam, et no pungctur, et post die punxi te in pede. 
Si dicat quod sic, signum est leprae. 

He also presents the first definite description of ulnar loss of 
sensation and paralysis. This speaks highly of his acute 
powers of observation: 

Item debet pungi cum acu a minimo digito manus ct sibi 
vicio usque ad brachium, quod in instis digitis magis aliis 
ratio est, quod sunt debiliores et ideo citius dimittuntur a 
regimine naturae. 

Taken as a whole, this presents a clear picture of LRL. Indi- 
vidual symptoms might be read as referring to HRL, but it is 
obvious that the descriptions as a whole cover one single 
condition, LRL. 



Conclusions 

From the earliest description of leprosy in the Mediterranean 
world through the Medieval period, leprosy is well de- 
.scribed. An exact correlation with modem, immunological 
classification is not possible. It is possible to define 
classification using the terms that are used in paleopathology. 
The literature descriptions cover LRL. No clear reference to 
HRL can be found. It is not possible to reconcile the descrip- 
tions with other diseases, nor is it possible to read descrip- 
tions of other diseases as leprosy. Available paleopathologi- 
cal findings present the same picture (e.g., M0ller- 
Christensen et al. 1952. 

We are left with a puzzling problem: Why does HRL only 
appear toward the end of the 19th century? Has the immu- 
nological response of the population changed? Is it a question 
of interaction with other mycobacterial diseases, such as 
tuberculosis? Or, most improbable, has Mycobacterium lep- 
rae changed? 



Zagreb Paleopathology Symp. 1988 



208 • Jobs G. Andersen 



Literature cited 

Andersen , J . G . 1 969 . Studies in the Medieval Diagnosis of Leprosy. 
Copenhagen: Costers Bogtrykkeri. 

1982. The Osteoarchaeological Diagnosis of Leprosy. Pro- 
ceedings of the Palaeopathology Association 4th European Meet- 
ing. Middleburg. 221-228. 

Aretaeus. 1828. Aretaei Cappadocis Opera Omnia. D. Caroivs 
Gottlob Kuhn, ed. Lipsiae: prostat in officina libraria C. 
Cnoblochii. 

Amaldus de Villa Nova (Sive Bachudne). 1309. Breuiarium prac- 
licae a capile ad pedem (Brew. II, Cap. 46), Napoli. 

BorthenL.M., andH.P. Lie. 1899. Die Lepra des Auges: Klinische 
Studien vonLyder Borthen. mit Pathologisch-Anatomischen Un- 
tersuchungen. Leipzig, GDR: Engelmann. 

Celsus, A.C. 1891. A. Cornelii Cels De medicina libri octo. Ad 
fidem optimorum librorum demto recensuit. adnotatione critica 
indicibusijue instruxit C. Daremberg. Lipsiae: B.G. Teubneri. 

Danielsen, D.C. 1873. Lungegaardshospitaiets Virksomhed i 
Treaaret \Sl\-lli. Nor.^k Mag Lcegev. 2(4):313-396. 

de Gaddesen, J. 1492. Rosa Anglica IV Lihris Distincta Papua. 

Moiler-Christensen, V., S.N. Bakke. , R.S.Melsom, and E. Waaler 
1952. Changes in the Anterior Nasal Spine and the Alveolar 
Processof the Maxillary Bone. InternationalJournal of Leprosy. 
20:335-340. 



Oribasius. 1851-1876. Oeuvres d'Oribase. Translated by Drs. 

Busscmakcr and Daremberg. Paris: Impr. nationale. 
Plinius. 1829. Ajason de Grandsagne . Histoire Naturell de Pline. 

Paris. 
Ridley, D.C and W.H. Jopling. 1966. Classification of Leprosy 

According to Immunity. International Journal of Leprosy. 34: 

255. 
WHO Study Group. 1982. Multidrug Therapy in Leprosy. Geneva. 



Summary of audience discussion: In Hawaii it was possible to 
demonstrate a chronological succession of changes from an initial 
low ratio of tuberculoid (high resistance)/lepromatous (low re- 
sistance) leprosy forms to a later reversal of this ratio. If an elevated 
value for this ratio reflects a longer duration of leprosy within a 
pt)pulation (and adaptation by development of resistance to it) then 
it would be interesting to determine this ratio among both current 
living populations throughout the world and in antiquity. Lack of 
available statistics limits study of modem groups, and absence of 
facial destruction makes it very difficult to differentiate the two 
forms in archeological skeletal populations. In modem p<5pulations 
local secondary mycotic infections of the extremities are common 
owing to loss of sensation resulting from the neuropathy. Death in 
antiquity may have been due primarily to amyloidosis, as it is now. 



Zagreb Paleopalhology Symp. 1 988 



Arthritis 



Rheumatoid erosive arthropathy as seen in 
macerated (dry) bone specimens 

James C.C. Leisen, Howard Duncan, and J.M. Riddle 



By definition, the process of erosion 
means a gradual wearing away of a sub- 
stance. Medically, this term is fre- 
quently used to describe a focal loss of 
tissue such as occurs in the develop- 
ment of an ulcer. Rheumatologists use 
the term erosion more specifically to 
denote a focal loss of articular cartilage 
and/or bone. The affected area there- 
fore appears radiolucent on x-ray films. 
Radiographic erosions can be detected 
in a number of rheumatic diseases in- 
volving peripheral joints, and of these, 
rheumatoid arthritis is the paradigm. 

Rheumatoid arthritis can be defined 
clinically by a set of criteria (Ropes et 
al. 1958:175), but none of these fea- 
tures alone, including radiographic ero- 
sions, is specific for this type of arthri- 
tis. When summated, however, the 
various clinical and laboratory findings 
describe a cadre of patients who have a 
chronic, nonbacterial, noncrystalline, 
symmetrical polyarthritis in which 40 
to 85% show bony erosions by exam- 
ination of anteroposterior radiographs 
of the hand (Mitchel and Fries 1982; 
481). Pathologically, the erosion ap- 
pears to be related to chronic infiamma- 
tion and proliferation of the synovial 
membrane, that is. the formation of 
rheumatoid pannus. Contact of the pan- 
nus with articular cartilage and/or bone 
promotes a focal loss of underlying 
tissue creating the erosion that is dem- 
onstrated by radiologic examination of 
the joint. 

Although some radiopathologic cor- 
relations of the rheumatoid erosion in 



peripheral joints have been made (Res- 
nick and Niwayama 1981:907), we are 
unaware of any published studies on the 
appearance of the rheumatoid erosion 
in macerated (dry) bone. Such a study 
might be useful to paleopathologists as 
a frame of reference for interpreting 
skeletal material. For this reason, we 
have described the morphologic fea- 
tures of the rheumatoid erosion as seen 
in macerated (dry) bone of surgically 
removed metacarpal heads and tibial 
plateaus. In our series of over 1000 pa- 
tients with rheumatoid arthritis seen in 
the Rheumatology Clinic, approxi- 
mately 50% have clinical involvement 
of the second and/or third metacar- 
pophalangeal joint and knee. 

Materials and methods 

Twenty-six second and third metacarpal 
heads were obtained from the hands of 
13 patients with classic rheumatoid ar- 
thritis. Ten specimens from eight pa- 
tients were selected for study because 
they contained residual articular car- 
tilage and adjacent pannus. Included in 
this series were six women and two 
men. Their mean age was 56 years 
(range 29-72 years) and the average 
duration of their disease was 7.9 years 
(range 4-20 years). 

Tibial plateaus were collected from 
the knees of seven other rheumatoid pa- 
tients. This group included six women 
and one man. Their mean age was 66 
years (range 61-72 years). All of these 
samples were available because it was 



necessary to remove the diseased joints 
in order to introduce an artificial joint. 

Control samples, 28 second and third 
metacarpal heads as well as 14 tibial 
plateaus were obtained from seven 
cadavers. The mean age of this group of 
three women and four men was 71 
years (range 41-83 years). Their 
causes of death were acute myocardial 
infarction (4), congestive heart failure 
(2), and a cerebrovascular accident ( 1 ). 
Tibial tables were also collected from 
six patients who required an above-the- 
knee amputation because of peripheral 
vascular occlusive disease. This series 
contained equal numbers of men and 
women. Their mean age was 72 years 
(range 64-85 years). 

The articular cartilage on all of the 
joint surfaces was examined under the 
dissecting microscope to detect car- 
tilage fibrillation or the presence of 
pannus. Radiographs of each metacar- 
pal head and tibial plateau were also 
taken to locate erosions and cysts. 

Subsequently, the specimens were 
macerated using 5.25% sodium hypoc- 
hlorite (Clorox) for approximately 24 
hours to completely remove the soft 
tissue. This step of the process was ver- 
ified by examination with a dissecting 
microscope. Following maceration, 
each specimen was defatted in acetone, 
air dried, mounted on aluminum stubs, 
and sputter coated with a thin layer of 
gold-palladium. This procedure not 
only permitted study by scanning elec- 
tron microscopy as previously de- 
scribed (Leisen et al. 1988: 17) but also 



Zaftreh Pateopaihology Symp. 1988 



211 



212 • James C.C. Leisen, Howard Duncan, and J.M. Riddle 



allowed examination with the naked 
eye or a dissecting microscope. 

We used the following terms to de- 
fine specific anatomic sites: Articular 
surface indicated the joint surface orig- 
inally covered by articular cartilage. 
The chondro-osseous junction defined 
the discrete line of contact between ar- 
ticular cartilage and bone at the joint 
periphery. Para-articular bone referred 
to epiphyseal bone anatomically lo- 
cated within the joint capsule and adja- 
cent to the chondro-osseous junction. 

Bony features described were the 
following; Holes were defined as any 
circumscribed break in the bony sur- 
face which exposed the marrow space 
or underlying trabecular bone (Duncan 
et al. 1987:1212). The edges of the 
holes were called sclerotic if they were 
rounded and slightly raised and/or 
thickened. An osteophyte was defined 
as any bony proliferation on or around 
the edge of the articular surface. 




Figure I . Hemisection of cadaver metacarpal head (left) and a rheumatoid metacar- 
pal head (right) showing erosion of articular surface associated with the infiamma- 
tory process; x 2. 



Results 



GROSS OBSERVATIONS AND 
DISSECTING MICROSCOPE VIEWS 

The unmacerated cadaver and amputee 
specimens (metacarpal heads and tibial 
plateaus) showed no pannus formation 
and only minimal articular cartilage 
fibrillation by examination with the 
naked eye. No radiographic chondro- 
calcinosis was seen. 

The articular surface, chondro-os- 
seous junction and para-articular struc- 
tures on macerated control samples 
were easily identified. Prominent fea- 
tures of the control macerated metacar- 
pal heads included: ( I ) condylar emi- 
nences which were most pronounced 
on the radial side, (2) a convoluted 
chondro-osseous junction, and (3) deep 
bony invaginations in the valleculac 
just posterior to the condylar emi- 
nences. These valleculae contained at 
least one dominant hole which was the 
site of entry of blood vessels originally 
supplying the bony epiphysis (Figure I , 
left). 



The medial and lateral plateaus of 
tibial tables removed from the cadavers 
and above-the-knee amputees were dis- 
tinct and separated by a central, ele- 
vated prominence (Figure 2). The artic- 
ular surfaces of the plateaus appeared 
smooth when viewed with the naked 
eye or the dissecting microscope. 

Gross examination of the rheumatoid 
specimens by contrast showed varying 
degrees of architectural destruction and 
variable amounts of pannus. Partial to 
complete resorption of the articular sur- 
face was seen in the macerated speci- 
mens. Loss of the articular surface on 
the rheumatoid metacarpal heads was 
most noticeable on the condylar emi- 
nences where seven of ten specimens 
showed complete resorption and three 
samples showed partial destruction 
(Figure I , right). In three specimens, 
the articular surface over the condyles 
was also perforated by many large 
holes. A small cap of residual surface 



remained intact on the radioulnar as- 
pect of five metacarpal heads. In ail 
specimens, there was circumferential 
loss of the chondro-osseous junction, 
and the para-articular bone was 
grooved as well as excavated. Many 
holes showed no evidence of sclerosis 
around their edges. Ebumation was 
seen on the articular surface in two of 
the rheumatoid specimens (Table 1). 
The rheumatoid tibial plateaus often 
showed that the articular surfaces were 
ebumated toward the intercondylar 
areas. Both the submeniscal and central 
surfaces of the plateaus contained many 
holes without sclerotic rims through 
which the marrow space and/or tra- 
becule were visible. In some areas the 
chondro-osseous junctions were oblit- 
erated. Para-articular bone contained 
low ridges of small bony osteophytes 
(Table 2). The intercondylar area in all 
specimens had many holes with little 
surrounding sclerosis (Figure 3). 



Ziifireh Pulftipatluil(t}>y Symp. 1988 



Rheumatoid erosive arthropathy in macerated bone specimens • 213 




Figure 2. Macerated control tibia! table from amputee. Note minimal change (focal 
collection of small holes in the lateral plateau (left); x 1 V: 



TaDLE 1. Summary of morphologic changes 
observed on rheumatoid metacarpal heads 

Frequency (%) 

DlSShCIlNG MICROSCOPE (6-IOX) 

Articular surface 
Dome 

Complete resorption 2/10 (20%) 

Partial resorption 8/10 (80%) 

Holes 2/10 (20%) 

Condyle 

Complete resorption 7/10 (70%) 

Partial resorption 3/10 (30%) 

Holes 3/10 (30%) 

Eburnation 2/10 (20%) 

Chondro-osseous junction 

Vallecular resorption 10/10 (100%) 

Para-articular bone 

Complete destruction 4/10 (40%) 

Holes 6/10 (60%) 



SCANNING ELECTRON MICROSCOPE (lOOX) 

Resorption lacunae at sites 10/10 (100%) 
of calcified tissue destruction 




TAni P 2. Comparison between macerated tibial 
plateaus of patients with rheumatoid arthritis (RA) 
and control subjects 



Figure 3. Macerated rheumatoid tibial table; x l'/?. 







R.4 


Control 


Bone thickness 




thin 


normal 


Osteophytes 
Eburnation 
Holes in articu 


lar surface 


few 

± 
+ + + 


± 
+ 


Holes in intercondylar area 


+ + + 


- 


Holes in para - 


articular area 


+ + 


- 



Zagreb Paleopathology Symp. 1988 



214 • James C.C. Leisen, Howard Duncan, and J.M. Riddle 




Figure 4. Articular surface of a rheu- 
matoid metacarpal head showing an 
eroding front covered with continuous 
resorption bays and an adjacent miner- 
alized surface with prominent chondro- 
cyte lacunae (volcanoes); x 560. 



SCANNING ELECTRON MICROSCOPIC 
OBSERVATIONS 

The articular surface of the macerated 
specimens (both control and rheu- 
matoid specimens) was covered by nu- 
merous volcanolike structures. These 
were identified as mounds of mineral 
enclosing lacunae which would have 
originally contained a single or several 
chondrocytes (Figure 4). 

At a higher magnification, many 
small holes were seen perforating the 
subchondral plate of both the medial 
and lateral plateaus of the tibial tables 
collected from the controls. These 
holes were concentrated at a submenis- 
cal location on the medial plateau and at 
a central location on the lateral plateau. 
In contrast, various-sized holes pene- 
trated the subchondral plate covering 
the medial and lateral plateaus of the 
rheumatoid tibial tables. No distinct 
distribution pattern of holes was ob- 
served for the plateaus of the rheu- 
matoid tibial table. Rather, the holes 
frequently were present in both the sub- 
meniscal and central locations of a 
plateau. 



The articular surface of the rheu- 
matoid specimens also showed focal 
collections of continuous resorption 
bays, an erosion with a morphology 
characteristic of osteoclastic activity 
(Figure 4). 

Discussion 

Our series included metacarpal heads 
and tibial plateaus removed from con- 
trol subjects and patients with chronic, 
classic rheumatoid arthritis. The joints 
of the rheumatoid patients were func- 
tionally impaired and painful to the ex- 
tent that the joint dysfunction necessi- 
tated surgery and replacement with 
prostheses. In this group, the rheu- 
matoid erosion had characteristic fea- 
tures which included; (I) partial or 
complete resorption of the articular sur- 
face, (2) obliteration of the chondro- 
osseous junction, and (3) minimal para- 
articular osteophytosis. The remaining 
bony tissue, regardless of location, 
contained holes or perforations through 
the surface which often exposed epi- 
physeal trabecular bone and marrow 
space. Although histologic features 



were variable, the scanning electron 
microscope consistently revealed pa- 
tches of continuous resorption bays at 
the eroded surfaces and lining the chan- 
nels of many holes. 

A review of the literature contained 
only four published papers (Table 3) in 
which an erosive arthropathy was sug- 
gested through the examination of dry 
bone (Klepinger 1979: 1 19; Ortner and 
Utermohle 1981:23; Rogers et al . 1 98 1 : 
1668; Thould and Thould 1983:1909). 
Seven skeletons were examined and six 
were found to show evidence of appen- 
dicular and axial (Ortner and Uter- 
mohle 1981: 23) bony defects sugges- 
tive of erosion. These defects were 
studied by visual and radiographic ex- 
amination. Although the authors sug- 
gest a variety of disease entities, we 
feel that the basic issue of "what is an 
erosion" needs to be addressed using 
radiographs and different microscopic 
approaches including light microscopy 
and scanning electron microscopy as il- 
lustrated in our study. 

The peripheral joints of a number of 
erosive arthropathies such as seronega- 
tive rheumatoid arthritis and the spon- 



Zagreb Pulenpathnloiiy S\mp. 19HH 



Rheumatoid erosive arthropathy in macerated bone specimens 'IIS 



Table 3. Summary of published studies describing an erosive arthropathy seen in dry 
archeological bone 



Author 



Site 



Age of 
specimens 



Material 



Rogers et al. 1981 Britain A.D. 1200 



Ortner and 
Utermohle 1981 
Klepinger 1979 

Thould and 
Thould 1983 



3 of 400 skeletons: 3 males with erosive disease, 

possible gout (1), psoriatic arthritis (1), 

rheumatoid arthritis 
Alaska >A.D. 1200 1 female skeleton age 30-35, polyarticular 

erosive disease 
Sicily 330-210 B.C. 1 male skeleton with distribution of abnormalities 

suggesting rheumatoid arthritis 
Britain A.D. 0-400 2 of 416 skeletons: 1 male, 1 female with erosions 

involving wrist and metacarpals 



dyloarthropathies have yet to be studied 
in this manner. In addition, morpho- 
logic surveys of patients with early and 
presumably less severely disabling 
rheumatoid arthritis might reveal ero- 
sive features that would be helpful in 
establishing the existence of erosive ar- 
thropathies in paleopathologic skeletal 
material. 

Finally, although the word "erosion" 
implies a focal defect in bone and/or 
cartilage, as seen radiographically, this 
type of focal change was not a feature 
of the specimens examined in this 
study. Rather, the rheumatoid erosions 
we observed were more extensive and 
included the sum of the anatomical de- 
fects noted in the articular surface, 
chondro-osseous junction, and para- 
articular bone. It appears that a multi- 
discipline approach that includes the 
distribution of joint lesions, radio- 
graphic evaluation of affected joints, 
and a careful morphologic survey of the 



joints using both light as well as scan- 
ning electron microscopy may be nec- 
essary to interrelate findings on modem 
patients with classic rheumatoid arthri- 
tis to joint lesions present in ancient 
skeletal remains. 

Literature cited 

Duncan, H., J. Jundt. J. Riddle, W. Pitch- 
ford, andT. Christopherson. 1987. Tibial 
Subchondral Plate — A Scanning Elec- 
tron Microscope Study. Journal of Bone 
and Joint Surgery: 69A: 1 2 1 2- 1 220. 

Klepinger, L. 1979. Paleopathologic Evi- 
dence for the Evolution of Rheumatoid 
Arthritis. American Journal of Physical 
Anthropology. 50: 1 19-122. 

Leisen, J., H. Duncan, J. Riddle, and W. 
Pitchford. 1988. The Erosive Front: A 
Topographic Study of the Junction be- 
tween Pannus and the Subchondral Plate 
in the Macerated Rheumatoid Metacarpal 
Head. Journal of Rheumatology. 15:17- 



Mitchell, DM., and J.R Fries. 1982. An 
Analysis of the American Rheumatism 
Association Criteria for Rheumatoid Ar- 
thritis. Arthritis and Rheumatism. 25: 
481-487. 

Ortner, D.J., and C.J. Utermohle. 1981. 
Polyarticular Inflammatory Arthritis in a 
Pre-Columbian Skeleton from Kodiak Is- 
land, Alaska, USA. American Journal of 
Physical Anthropology. 56:23-3 1 . 

Resnick, D.. andG. Niwayama. 1981. Di- 
agnosis of Bone and Joint Disorders, vol . 
2. Philadelphia: W.B. Saunders. 

Rogers, J., 1. Watt, and P. Dieppe. 1981. 
Arthritis in Saxon and Medieval Skel- 
etons. British Medical Journal. 283: 
1668-1670. 

Ropes, M.W., G.A. Bennett. S. Cobb, R. 
Jacox, and R.A. Jesspar. 1958. Revision 
of Diagnostic Criteria for Rheumatoid 
Arthritis. Bulletin of Rheumatic Dis- 
eases. 9:175-176. 

Thould, A.K., and B.T Thould. 1983. Ar- 
thritis in Roman Britain. British Medical 
Journal, 287:1909-1911 



Zagreb Paleopathology Symp. 1988 



Paleopathology of rheumatism in paintings 

Jan Dequeker 



The pathology and history of rheumatism and especially of 
rheumatoid arthritis are still poorly understood. Insight re- 
garding the pathology may be enhanced through perspectives 
provided by the history of disease. Short (1974), in his re- 
view of the historical documents and reports published on 
paleopathological specimens, was unable to find convincing 
evidence for rheumatoid arthritis earlier than the 1 7th century 
A.D. prior to Sydenham's description of the disease in 1676. 
This observation led him and many others to speculate that 
rheumatoid arthritis is a recent disease, perhaps reflecting 
recent changes in the human environment. Thus the clarifica- 
tion of the history of rheumatoid conditions in human popula- 
tions is of considerable anthropological interest. 

Ankylosing spondylitis and some types of erosive poly- 
arthritis were present from earliest times (Onner and Uter- 
mohle 1981). A few examples of what could have been mild 
rheumatoid arthritis have been discovered, but the prolifera- 
tive, erosive disorders with spinal involvement (possibly 
psoriasis or Reiter's syndrome) seem more common. Have 
the rheumatic diseases changed? is rheumatoid arthritis diffi- 
cult to identify? or is it a relatively recent disease? Because 
the question remains open I have directed my interest in 
paleopathology of rheumatism to paintings, which may dis- 
close soft tissue evidence of diseases of ancient time, which 
are poorly seen in skeletal remains (Dequeker 1977). The use 
of the visual arts, for example paintings, as a tool for paleo- 
pathology research has advantages and disadvantages which 
should be kept in mind clearly. 

The advantage is that rheumatic diseases affect primarily 
soft tissue (synovia, tendons and cartilage) and only sec- 
ondarily after many months and years of disease can bone 
lesions be detected. In paintings and sculptures the defor- 
mities due to soft tissue swelling, tendon contractions, and 
joint subluxations, resulting in discomfort and disabilities, 
can be discerned and detected by an experienced clini- 
cian. 

The disadvantage of visual arts is that the artists do not 
necessarily make portraits of their subjects and may alter 
anatomical characteristics according to their "feeling" at the 
time of their work. While a visit to a museum may seem to 
yield a rich trove of medical illustrations, things are not 
always what they seem. Diagnostic acumen applied to paint- 
ings can be misleading if not tempered with a knowledge of 
216 



artistic conventions (as mannerisms) and historical context 
(Ehdich 1987). 

Taking into account the above restrictions, 1 have the priv- 
ilege to study paintings made by famous Flemish medieval 
artists who lived in the area where I practice my speciality of 
clinical rheumatology. 

Paleopathological findings of rheumatism in paintings will 
now be reported. The adage that one only sees what one 
knows is certainly applicable to this field of research. A large 
clinical background in rheumatology is necessary to recog- 
nize early clinical features, and to put them in context to 
make a firm diagnosis. 

Rheumatoid arthritis 

Perhaps the most convincing evidence of rheumatoid arthritis 
in paintings is the arthritis of the housemaid of Jacob Jordaens 
( 1 593- 1 678) as seen in the painting of Jordaens's own family 
(Figure 1). 

In order to convince people inexperienced in this field, I 
have chosen a picture (Figure 2) of a hand of one of my 
rheumatoid arthritis patients of about the same age, disclos- 
ing the main features: swelling of the metacarpophalangeal 
joints, the proximal interphalangeal joints, and the wrist. 
This example of rheumatoid arthritis is sufficiently demon- 
strative so that it has been chosen to illustrate the latest, 
authoritative textbook of rheumatology in Great Britain 
(Scott 1986). 

Another yet unpublished but very characteristic hand and 
wrist deformity of rheumatoid arthritis is one I found recently 
at the Escorial Museum near Madrid in the painting of an 
anonymous artist of the Dutch school of the mid 1 5th or early 
16th century. 

A number of other deformities resembling features seen in 
rheumatoid arthritis have been discovered in the painting of 
Jan Rombauts (ca. I5(X)) "Christ appearing to St. Peter" 
(Leuven, Stedelijk Museum); in the portrait by Joos (Justus) 
Van Gent (1430-1475) of Federigo de Montefeltre (Urbino, 
Ducal Palace); in the drawing by Jan Van Eyck (ca. 141 1) of 
John IV, Duke of Brabant; and in the painting "The Dona- 
tors" (Brussels) (1525-1530) by Jan Gossaert, also called 
Mabuse, showing flexion contraction of the second, foUrth, 
and fifth finger of the left hand (Figure 3). 

Zagreb Paleopalhology Symp. IV8S 



Paleopathology of rheumatism in paintings • 217 




Figure 2. Synovial swelling of proximal inter- 
phalangeal, metacarpal, and wrist joints in a patient 
suflering from rheumatoid arthritis. 



Figure 1. Jacob Jordaens: The painter's family (de- 
tail); Madrid, Prado. The maidservant's right hand 
shows swelling of metacarpal and proximal inter- 
phalangeal joints. 




Figure 3. Jan Gossaert (Mabuse); The Dona- 
tors; Brussels, National Museum. Flexion con- 
tractures of the man's right hand. 



A few years ago I noticed two other remarkable examples 
of rheumatoid deformities of the hand in late Gothic paint- 
ings: one by M. Van Heemskerck ( 1498-1574) titled "Altar 
Panels with Donors" (Figure 4) and the Avignon Pieta 
(± 1470) at the Louvre in Paris, by a Southern French Master 
entirely under the influence of the Flemish School ( Figure 5). 
The left hand of one of the donors and the right hand of St. 
John show grossly deformed joints with fingers twisted and 
turned sideways or bent backwards. 

Zagreb Paleopathology Symp. I9S8 




FiGURi: 4. M. van Heemskerck: Altar Panels 
with Donors; Vienna, Kunsthistorisch Museum. 
Rheumatoid deformities of the fingers and atro- 
phy of the dorsum of the hand. 




Figure 5. Southern French Master: Avignon 
Pieta; Avignon. Twisted fingers of St. John's 
right hand turned sideways and bent backward. 



218 • Jan Dequeker 




Figure 6. St. Blankaart: Front page of book on podagra and 
gout. The young man sitting in a wheelchair has an ankylosed 
back and knee joint. 



Ankylosing spondylitis 

During my search for rheumatic diseases in visual arts I have 
encountered only one example of possible ankylosing spon- 
dylitis. In the front page of the work of St. Blankaart (1684) 
"Van het podagra en vliegende jigt" on podagra and gout, a 
young male sits with a stiff back in a wheelchair with an- 
kylosed knee and possibly ankylosed hip, while another male 
sits in a chair with a walking stick near a fire (Figure 6). Of 
the other two patients, one lying in bed is being bandaged 
around the legs and receiving medicine in a spoon, while the 
other in the foreground is undergoing cauterizations at his 
knee. Although they all seem to suffer from rheumatism, it is 
only the one in the wheelchair who can be identified as a 
probable case of ankylosing spondylitis. The others could be 
polyarticular gout or any other rheumatic disease entity in- 
volving one or several joints. 




Figure 7. Jan Van Eyck: The Virgin with the Canon (detail); 
Bruges, Municipal Museum. Temporal arteritis — polymyal- 
gia rheumatica. 

Polymyalgia rheumatica 

Indirect indications of polymyalgia rheumatica, a rheumatic 
inflammation characterized by shoulder and hip girdle mus- 
cle stiffness and often associated with temporal arteritis, are 
seen in the painting by Jan Van Eyck (ca. 1385-1440) of the 
Holy Virgin with Canon Van der Paele (Figure 7). The Canon 
is clearly suffering from temporal arteritis, with scar forma- 
tion and loss of hair of the eyebrow and in front of the left ear. 
For the sake of completeness, it should be mentioned that he 
also has a cellular mole and a sebaceous cyst on the left ear. 
Historical data on Canon Van der Paele published in the 
Canadian Medical Association Journal ( Dequeker 1 98 1 ) sup- 
port my clinical diagnosis of polymyalgia rheumatica. Ac- 
cording to the minutes of the cathedral chapter, he began 
having difficulty in attending the morning service in Novem- 
ber 143 1 . By the time the painting was done ( 1 434), the aging 
Canon was forced to stay home, first in the morning and later 
for the whole day, because of rheumatic pain with morning 
stiffness, general weakness and ill health. This illness was 
not fatal, however, and he survived the first symptoms for 12 
years — a history compatible with the natural course of poly- 
myalgia rheumatica. 

Zagreb Palcopaihology Symp I98S 



Paleopathology of rheumatism in paintings • 219 




FiGURK 8. Patient suffering from biopsy-proved 
temporal arteritis and polymyalgia rheumatica. 



In order to illustrate the great realistic capacity of Jan Van 
Eyck, and the likelihood of our diagnosis, the clinical picture 
of a patient with identical features at the temporal region and 
whose biopsy showed giant cell arteritis is shown (Figure 8). 

Recently I discovered that a German dermatologist. Roth 
(1969), had made the same diagnosis in 1969. Mcige ( 1924) 
described vascular abnormality in the temporal region in four 
paintings, but did not mention the painting of Jan Van Eyck. 

The Canon was probably not the only sufferer from this 
disease during these centuries. Signs of temporal arteritis can 
be seen in Piero di Cosimo's Portrait of Francesco Gambetti 
( 1505), now in the Rijksmuseum. Amsterdam. 

Osteoarthritis 

In another painting by Jan Van Eyck, "The Lamb of God" 
retable (Ghent), 1 found one of the few convincing evidences 
of osteoarthritis in paintings. The distal intcrphalangeal joint 
of the thumb of St. John Baptist shows clearly Hebcrdcn 
nodes (Figure 9), the overall landmark of generalized os- 
teoarthritis as shown in a picture of a contemporar>' patient 
(Figure 10). A similar Heberden-likc (knucklepad-like) 
swelling around the joints can be seen in two paintings 
by Bernardo Strozzi (1581-1644): "The Old Coquette" 
(Moscow) and "The Lute Player" (Vienna). This prominence 
at the bending of fingers might be a convention of mannerism 
as suggested by Ehrlich (1987). 

Ziturvh Pateopalholo^y Symp. I9HH 




Figure 9. Jan Van Eyck; The Lamb of God reta- 
ble (detail); Ghent, St. Bavo Cathedral. Heber- 
den nodes on the thumb of St. John Baptist. 




Figure 10. Patient with llcbcrden nodes at the distal intcr- 
phalangeal joints. 



220 • Jan Dequeker 



Discussion 

Since the publication of my first findings in the British Medi- 
cal Journal in 1977, and more extensively in Organorama in 
1979, two further papers on rheumatoid arthritis in art have 
been published. 

Appclboom and associates (1981) described a peculiar 
tendency of Peter Paul Rubens (1577- 1640) to paint appar- 
ent swelling of the wrists and deformities of the hands, and it 
has been suggested that either he or his second wife, Helena 
Fourment. or both, may have had rheumatoid arthritis. In- 
deed, biographical information on Rubens suggests that he 
suffered from rheumatism. In his abundant correspondence, 
the term "gout" is used to define the recurrent pains and 
swellings afllicting his hands and feet. 

Alarcon-Segovia and associates (1983) pointed out that 
the "Portrait of a Youth," painted in 1483 by the Florentine 
artist Sandro Botticelli, has features of rheumatoid arthritis in 
the hand of the subject, who would be young enough to be 
considered as having juvenile arthritis. This painting has also 
been discussed by Short (1974) as a possible example of a 
rheumatoid arthritis hand, although he admits that it also 
could be an artistic convention or stylistic trait, since Bot- 
ticelli's hands often have this appearance. When painting an 
extended hand Botticelli, like many other painters of the 
Renaissance, placed both middle fingers together and the 
second and fifth apart, as if to relieve the monotony the 
fingers would create if all were spread. A bent fifth finger is 
often encountered not only in Botticelli's paintings but also in 
the paintings of Rogier van der Weyden and many others. 

In another painting by Botticelli, "The Birth of Venus," 1 
recently described swelling of the proximal interphalangeal 
joints and a sausagelike swelling of the left index finger 
(Dequeker 1984). Is it significant that the fingers of the right 
hand point in the same direction as the drifting hairlocks? 

An interesting anecdote is that the model for Venus was a 
well-known individual, namely the 16-year-old Simonetta 
Vespucci, girlfriend of Giuliano di Piero, brother of Lorenzo 
il Magnifico. Simonetta died a few years later from tuber- 
culosis (Alarcon-Segovia 1985). 

It is obvious that caution is called for in drawing medical 
conclusions from paintings and engravings. This is particu- 
larly the case when the hands are taken as the basis, for hands 
are often used by painters as a means of expression for feel- 
ings and sometimes as the hallmark of a particular school of 
painting. For example, it is striking to note that many fingers 
in the canvases of Rogier van der Weyden show very fine 
long fingers, often with a clinodactylic deformation of the 
little finger. 

It is also well known that most of the figures in El Greco's 
paintings show a picture of Marfan's syndrome. The abnor- 
malities described in this article are of a different nature. 
They are not the consequence of a style, except perhaps for 
the hands in the painting by Jan Gossacrt; these could point to 
an expression of a mannerism typical of this artist. Similar 



deformations of the hands can be seen in a portrait of a 
woman in the Rijksmuseum in Amsterdam and in that of the 
man with the garland of roses in the National Gallery in 
London. Both of these works are ascribed to Jan Gossaert. 

Probably a rheumatologist sees more in the pictures of 
cripples than another doctor or a layman because of the 
knowledge he has acquired in daily practice. What we do not 
know, we do not see. Although none of the deformations and 
swellings of the joints which have been found constitute 
irrefutable examples of rheumatoid arthritis, they neverthe- 
less give grounds for a strong suspicion that polyarthritis 
occurred so frequently in the Middle Ages that it must have 
caught the attention of the masters, and this at a period in 
which infectious diseases such as leprosy and tuberculosis 
dominated pathology in every field. Arthritis was recognized 
in all sections of the population, among rich and poor, and 
men and women alike. 

Ten out of 24 paintings, described in full elsewhere, in 
which arthritic lesions were recognized, represent donors or 
well-known personalities of whom a "portrait" was made 
(Dequeker 1987). This supports the idea that in fact these 
individuals might have been suffering from rheumatic dis- 
eases. Almost all of these paintings were in the time of the 
Flemish realistic school infiuence, introduced by Jan Van 
Eyck. Since scrupulous recording like this of wrinkles, 
veins, warts, stubble on the chin, and congenital malforma- 
tions are typical for 15th- 16th century Flemish art, the 
rheumatoid-like hand deformities cannot be ascribed to 
carelessness, incompetence, or mannerism of the painters. 

It is thanks to the realism of the Flemish, Dutch and Italian 
schools of the late Gothic era that we can recognize these 
deformities. During the Renaissance and the Baroque the 
figures were so idealized and perfected that signs of disease 
are seldom recognizable in the works of these periods. Al- 
though the paintings in those earlier days were generally 
commissioned by patrons who also figured in them, the 
painters did not always spare their benefactors, as we saw in 
Jan Gossaert's and Van Heemskerck's paintings, and in the 
portraits of Federico da Montefeltro, Michelangelo, Canon 
Van der Paele, Jordan's Servant, Gambetti, Aegidius, Eras- 
mus, and Vespucci. 

These descriptions and pictures do not, of course, provide 
any scientific proof that rheumatoid arthritis and associated 
systemic disorders occurred frequently in the Middle Ages. 
But the argument that rheumatoid arthritis does not occur in 
old paintings equally does not provide scientific proof for the 
assertion that rheumatoid arthritis is a recent or modem dis- 
ease. The main reason why they were not noted historically is 
that the mean lifespan was too short for a sufficient number of 
cases to develop and be recognized as examples of a specific 
disease. Rheumatoid arthritis was rare becau.sc age expecta- 
tion was low, and potential sufferers died before contracting 
the disease. There is already evidence that this is a reason for 
the low prevalence of rheumatoid arthritis in underdeveloped 
countries. In contrast, ankylosing spondylitis is historically 

Zxif^reh Paleopathoto^y S\mp I9HS 



Paleopathology of rheumatism in paintings • 221 



well-documented in human remains because this inflamma- 
tory rheumatic disease preferentially affects younger people. 
The discoveries of rheumatic disorders in the paintings and 
drawings of the Late Middle Ages described here neverthe- 
less make the current view (that rheumatoid arthritis is a 
relatively recent complaint) a topic for discussion. 

Literature cited 

Alarcon-S^govia, D. 1985. Botticelli and Arthritis. Arthritis and 
Rhctimatism. 28:6(X). 

Alarcon-Segovia. D., A. Latfon, and J. Alcocer-Varela. 1983. 
Probable Depiction of Juvenile Arthritis by Sandro Botticelli. 
Arthritis and Rheumatism . 26: 1 266- 1 268 . 

Appelboom. T. , C. dc Boelpaepe, G. Ehrlich, and J. P. Famaey. 
1981 . Rubens and the Question of Antiquity of Rheumatoid Ar- 
thritis. Journal o] the American Medical Association, 245:483- 
486. 

Dequeker, J. 1977. Arthritis in Flemish Paintings (1400-1700). 
British Medical Journal. 1 : 1 203- 1 205 . 

1979. Rheumatism in the Art of the Late Middle Ages. 

Organorama, 16:9-19. 

1981 . Polymyalgia Rheumatica with Temporal Arteritis as 

Painted by Jan Van Eyck in 1436. Canadian Medical Association 
Journal. 124:1597-1598. 

1984. Arthritis in the Paintings of Sandro Botticelli. Ar- 
thritis and Rheumatism. 27: 1 196- 1 197. 



1987. Rheumatic Diseases in Visual Arts. In T. Ap- 
pelboom, cd. , Art, History and Antiquity of Rheumatic Diseases, 
31-40. Brussels: Elsevier Librico. 

Ehrlich, G.E. 1987. The Cover. Journal of the American Medical 
Association, 257:892. 

Meige, H. 1924. Presse Medicale, 26 April. 

Ortner, D.J., and C.J. Utcrmohle. 1981. Polyarticular Inflamma- 
tory Arthritis in a Pre-Columbian Skeleton from Kodiak Island. 
Alaska, USA. American Journal of Physical Anthropology. 
56:23-31. 

Roth, W.G. 1969. Arteriitis temporalis dargestellt an cinem 
Gemalde des Reichsmuseums in Amsterdam. Der Haularzt. 
20:330-332. 

Scott, J.T. 1986. Copeman's Textbook of the Rheumatic Diseases, 
vol. I. 6th edition. New York: Churchill Livingstone. 

Short, C.L. 1974. The Antiquity of Rheumatoid Arthritis. Arthritis 
and Rheumatism, 17:193-208. 



Summary of audience discussion: Attempts to trace the history 
of rheumatoid arthritis to periods earlier than a.d. 1650 are frus- 
trated by the style of painting prior to that date. Differences in 
pattern and symmetry assist the separation of rheumatoid arthritis in 
paintings from psoriasis or Reiter's syndrome to some degree but 
not infallibly. 



Zagreb Pateopaihology Symp. 1988 



Trauma 



Trauma and treatment in the British Isles 

in the Historic Period: A design for 

multidiscipHnary research 



Charlotte Roberts 



The study of disease processes in past populations has had a 
long history stemming from 19th century investigations. The 
skeletal remains of our ancestors have always attracted atten- 
tion and interest from scholars and amateurs alike, often with 
a somewhat startling obsession. Lay attitudes to study of 
human remains have also varied through time up to the pres- 
ent day; there is now little room or finances for superficial, 
unplanned study yielding results insignificant with regard to 
the archeology of the population as a whole. In addition, 
current problems concern the ethical aspects of the scientific 
study of recent, and even more distant, ancestors of indige- 
nous populations, notably the Aboriginal communities of 
Australia (Webb 1987). Prevention of study of ancestral re- 
mains and their removal from museums for reburial should 
be an issue of concern to all paleopathologists. The Paleo- 
pathology Association is at present heavily involved with this 
reburial issue (Hart and Ubelaker 1987). 

Paleopathology has, however, advanced over the years in 
terms of its credibility as a science and its recognition by 
archeologists as a valuable tool in reconstructing the past. It 
need hardly be said that the remains of people who lived 
many thousands of years ago are the nearest evidence which 
anybody can hope to obtain to rebuild a valid picture. Nev- 
ertheless, the discipline has some way to go before it is 
recognized and accepted as a useful tool for reconstruction of 
ancient societies. At times paleopathological studies, in Brit- 
ain at least, are criticized as being "unco-ordinated and des- 
perately undcrstafted; therefore there is little possibility of 
constructive exchange of views between the paleopathologist 
and archeologist" (Cramp 1983: 19). Obviously this is not the 
case for all countries where perhaps funding for research is 
more readily available, thereby providing an environment 
conducive to this interchange of ideas. 

Paleopathology is but one aspect of interpreting the struc- 
ture of past societies and, although contributing significantly 
to this aim, it cannot survive alone and in isolation from other 
disciplines in archeology. Alone it provides little construc- 
tive and interpretable data. Every aspect of archeological 

Zagreb Paleopaihology Symp. 1988 



Studies can contribute .something to an understanding of the 
complexities of the lives of peoples in antiquity. As Arnold 
said (1986:38), "Specialists must continue with their re- 
search; none need, nor has any right, to believe that their 
specialization is superior to any other; each must feed their 
data, observed patterns and generalizations to those who seek 
to take a more generalized overview of past human behavior, 
an overview which must incorporate all types of evidence." 

All experts in their own fields must collaborate to create an 
accurate interpretation of the society they are studying. One 
should try to use even fragmentary data, because, as Bisel 
and Angel said (1985:198): "It is by consideration of all 
factors together that more reliable conclusions can be 
drawn." Reece (1982:348) clearly is in agreement with this 
statement when he bemoans the lack of integration of all 
aspects of cemetery studies: "I have yet to find a report which 
integrates all these facts, and it is the separation of bones 
from bodies, and bodies from cemeteries and finds, that 
causes my dis-ease." Reece found a general failure to inte- 
grate human bone reports from Roman cemeteries in Britain 
with the cemetery report as a whole. He emphasizes 
(1977:355) "the incredible stupidity of digging a cemetery 
and then classing the major source of information as an op- 
tional appendix." 

Attempts at using integrated multidisciplinary evidence to 
reproduce particular aspects of a society, such as diet and 
changes in economy, have been successful in America 
(Gilbert and Mieike 1985; Cohen and Armclagos 1984) and 
anthropologists have advocated a close working relationship 
between them and archeologists (Osborne 1969). preferably 
in departments employing workers in both disciplines. Inter- 
pretation and understanding should be the ultimate aim of 
studying all types of archeological and related data. 

The following paper shows an attempt to use many differ- 
ent types of evidence to reconstruct how well or how badly 
past peoples managed injuries to the long bones and skull. 

Paleopathology by its very nature relics on diagnosis based 
on modem clinical medical method, and interpretation of 

225 



226 • Charlotte Roberts 



data in the ideal world has to be done with reference to 
clinical texts and experience. The diagnosis and interpreta- 
tion of trauma is. of necessity, heavily reliant on radiographic 
analysis, and this particular research is based very much 
around this theme. Correlation with other classes of evidence 
is without doubt essential to the potential success of interpre- 
tation of the data. 



History of trauma studies 

Trauma can be defined as any bodily injury or wound and 
may affect the bone and/or soft tissues of the body. Fractures 
can be defined as the result of any traumatic event which 
leads to a complete or partial break in the continuity of bone. 
Trauma is a common affliction of modem lifestyles, as it was 
in the past, and people do, and did, react to it in a variety of 
ways. Trauma is painful, visual and debilitating, and Withers 
(I960: 1 ) perhaps summarizes these thoughts on the implica- 
tions of trauma: "In times of stress, pain or of sorrow, the 
human being will go to any length to try and find help." In 
human skeletal studies it is difficult to be precise in aspects 
such as complications of particular fractures but it is essential 
to be aware of these potential complexities. Applied anatom- 
ical studies in paleopathology should be one of the first con- 
siderations. 

Data on fractures for paleopathologists in past years has 
appeared in four forms: (1) as part of a bone report (i.e., 
incidence of fractures), (2) as a specific study on fracture 
patterns in particular populations, (3) as a study of fractures 
of a specific bone, and (4) as part of a treatise on paleo- 
pathology. 

The quality and quantity of analysis and interpretation of 
trauma is determined by the worker's preferences or the arch- 
eologist's requirements for a bone report. In many cases 
basic descriptions of skeletons present is all that is provided 
or required. In other cases a more detailed report is appropri- 
ate. All human skeletal reports describe any traumatic lesions 
observed in the populations (e.g.. Wells 1982:161). Some 
literature has also appeared which exclusively describes trau- 
ma in a specific population (e.g.. Zivanovic 1984; Lovejoy 
and Heiple 1981; Jurmain this volume). In Britain, occasion- 
al publications specifically on ancient skeletal trauma have 
also appeared (see Manchester and Elmhirst 1 980; Manches- 
ter 1978; Courville 1965) but these have tended to concen- 
trate on the wound appearance and the potential weaponry 
causing the injury. 

Case studies of unusual pathological lesions (e.g. , Roberts 
1987) have been and always will be prolific in paleopathol- 
ogy, as the method is an efficient way of transmitting infor- 
mation. Studies concerning trauma have also appeared in this 
type of literature. Although useful, there is little possibility 
for synthetic study from isolated reports. 



Several books deal with paleopathology generally (Ben- 
nike 1985; Ortnerand Putschar 1981). Obviously, these vol- 
umes discuss trauma, but the very widespread nature of pal- 
eopathology precludes expansion of data on trauma into a 
more valid interpretation for human skeletal studies. 

In modem clinical literature the contributions to trau- 
matology are prolific and make comparison between modem 
and ancient trauma possible. Incidence rates of fractures, sex 
ratios and age ranges, causes, types of treatment, healing, 
and complications are all well documented. This provides 
an, as yet, unrealized potential for comparing ancient frac- 
tures with modem data. 



Present study 

The potential for the study of trauma in populations has not 
yet been fully appreciated. While trauma in osteoarcheologi- 
cal analysis is universally reported, there is often little expan- 
sion of the basic data. Fortunately, in Britain extensive 
documentary research and archeological excavation and in- 
terpretation has led to a considerable archive of information 
which can be utilized to supplement human skeletal observa- 
tions not only in trauma but in many other paleopathological 
studies. Obviously, limitations have to be realized, and col- 
laboration between the skeletal specialist and specialists con- 
versant with all types of evidence being used is essential. As 
Daniels ( 1978:28) stated, " Archaeology has become a sub- 
ject too complex for the simple polymath to handle." 

Considerable thought about trauma studies, developed by 
the author in 1983. led to a proposal for research. The hy- 
pothesis to be tested was as follows: Populations were capa- 
ble of and had the technology and intelligence to treat trauma 
in antiquity. To test this hypothesis the research design en- 
compasses: ( 1 ) study of dry bone evidence for trauma in the 
form of fractures of long bones (humerus, radius, ulna, 
femur, tibia and fibula) and the skull, using macroscopic 
observation and radiography; (2) correlation of this data with 
other classes of evidence to illuminate the knowledge of 
treatments and technology used in each time period from the 
Roman to late and post-Medieval eras. 

The rationale for the selective study of long bone and skull 
fractures is that injury to these areas of the body would be 
more detrimental to the individual's well being than, for 
example, a fracture of the rib, clavicle, or a peripheral bone. 
Trauma is extremely devastating not only skeletally but gen- 
erally to the body system. 

The main sources of evidence used were human skeletal 
remains, modern clinical comparative data, secondary docu- 
mentary sources, ethnographical studies, art forms, and ar- 
cheological data such as surgical artifacts, environmental 
data indicating hygiene, living conditions and diet relevant to 
healing of fractures. 



Zagreb Paleopathology Symp. 1988 



Trauma and treatment in the British Isles in the Historic Period • 227 



LIMITATIONS OF THE EVIDENCE 

There arc a number of significant restraints on the data for 
these classes of evidence but the main areas become readily 
apparent. They are brietly reviewed here and discussed in 
more detail later in the paper. 

FRAGMENTARY SKELETONS. Investigation of a large number 
of cemetery sites from different areas of the British Isles was 
considered essential to obtain a valid picture of trauma. How- 
ever, the number of cemetery sites examined precluded es- 
timation of an absolute incidence of particular fractures. Data 
was not available for counts of individual bones for most of 
the sites. First, it was not feasible in terms of time to under- 
take this work as part of the research, and second, it was felt 
that it was not a particularly relevant area of study for the 
subject matter of this project. 

AGE AT FRACTURE. Agc-spccific incidence rates of fractures 
have been quoted by many workers in human skeletal reports 
but, in fact, these data mean little. Fractures evident on skel- 
etons could have occurred at any time prior to death. There is 
currently no method of estimating at what age a fracture 
occurred in ancient skeletal material beyond about one year 
after the injury, unless the fracture occurred close to death 
and there is extant evidence of very new bone formation or 
primary callus. 

SUBADULT FRACTURES. Grccnstick fractures occurring in 
childhood, even in modem populations, may heal and re- 
model so well that the original fracture line may not be visible 
on x-ray. In ancient populations these fractures may not be 
recognized even macroscopically. 

RECENT ANTEMORTEM FRACTURES. Fracturcs Occurring 
shortly before death may be difficult to distinguish from 
postmortem fractures of bone due to burial and/or excavation. 

STRESS FRACTURES. Stress fractures will not be identified 
unless all the bones of every skeleton are x-rayed. Even so, 
many will not be evident on an x-ray. 

SKULL INJURIES AND BRAIN DAMAGE. Consideration of skull 
injuries and their potentially associated brain damage can be 
problematical. Some types of head injuries induce con- 
trecoup damage to the brain while others produce direct 
damage to the subjacent brain. In addition, complications of 
skull injury can be complex and multifactorial. 

TREPANATION. In somc cascs it is difficult to distinguish 
between postmortem holes in the skull and trepanation and, 
of those trepanations which have no injury associated with 
them, one can only speculate on the raison d'etre. 



ART AND LITERATURE. Representations of past events in an 
or literature are inevitably controlled by the author's or art- 
ist's preferences or interpretation, and their validity as evi- 
dence of disease or therapy is questionable. 

MODERN PRIMITIVE SOCIETIES. These populations are sepa- 
rated in both space and time from ancient British societies but 
they may be comparable in terms of their disease concepts 
and treatment. 

ARCHEOLOGiCAL EVIDENCE. Interpretation of archcological 
evidence is controlled by the remains studied. All material 
remains are a sample of what was actually deposited in the 
ground and many factors determine their survival and ex- 
cavation. For example, splints u.sed for fractures were proba- 
bly constructed from biodegradable material, such as wood, 
and either do not survive to be excavated due to site-specific 
soil conditions or were not buried with the skeleton. Most 
fractures seen by the paleopathologist are healed and there- 
fore do not need to remain splinted at death and burial. 

Notwithstanding the limitations present in all forms of 
archcological research, the potential for the study of trauma- 
tic lesions in human skeletal remains is considerable. 

This paper does not present a definitive analysis of results 
because the research program is still in progress. This report, 
which is therefore interim, seeks to outline the sources of 
evidence used and the rationale thereof, the observational 
methodology and the criteria of analysis of those sources. 

METHOD 

SKELETAL EVIDENCE 

The skeletal evidence for bone fractures is extensive as 
shown by previous analysis of human remains. This evidence 
occurs in varying incidence throughout different populations 
and periods of time, although there is, as yet, little data 
available on fracture incidence in the past. 

Location of skeletons in museums, archeology and an- 
thropology departments in universities, and in archcological 
units was often difficult. A total of approximately 30,000 
individuals were located in institutions around Britain. Ap- 
proximately 6000 individuals have been examined to date. 
An attempt was made to look at equal numbers of skeletons 
from the time periods of interest. Table 1 lists the cemetery 
populations studied (Figure 1). The Roman, Anglo-Saxon, 
Medieval, and post-Medieval periods were chosen for study 
because of the availability of skeletal material and contem- 
porary documentary, art, and archcological evidence for 
these eras. The availability and numbers of prehistoric re- 
mains in Britain would not give a representative study, and 
additional types of evidence of prehistoric context are not 
always available. 



Zagreb Paleopalholofiy Symp. 1988 



228 • Charlotte Roberts 



Table 1. Total numbers of skeletons examined 



Roman 



Anglo-Saxon 



Medieval 



Castle Street, Chester 


2 


Hamwih, Southampton 


104 


Margidunum 


15 


Binchester 


36 


College of Art, Gloucester 


29 


Willoughby-on-the-Wolds 


62 


Kingsholm 


8 


Empingham 


16 


Derby Racecourse 


71 


Stretton-on-Fosse 


55 


Rudston 


28 


Little Chester 


61 


Walkington 


18 


Leaden Hill 


41 


St. Bartholomew's, London 


34 


Rangoon, London 


2 


Cutlers Gardens, London 


18 


Pewsey 


101 


Woodcutts 


14 


Collingbourne Ducis 


28 


Rotherly Down 


14 


Winklebury Hill 


28 


Woodyates 


19 


Cheddar 


2 


Wor Barrow 


22 


Bedhampton 


76 


Ilchester 


45 


Portchester Castle 


21 


Knowle Bardnip 


1 


Snell's Corner 


45 


Compton Pauncefoot 


3 


Portsdown Hill 


25 


Taunton 


10 


Berinsfield 


88 


Lamyatf Beacon 


4 


Eccles 


150 


Bradley Hill 


23 


Raunds 


300 


Charlton Mackrell 


14 


Tanners Row 


200 


Northover 


8 


Misc. 


13 


Hicknell Slait 


1 






Chester Road, Winchester 


92 






Victoria Road, Winchester 


201 






Western Suburbs, Winchester 


14 






N. R., Winchester 


22 






Hyde Street, Winchester 


26 






District, Winchester 


14 






Gambier-Parry Lodge, 


93 






Gloucester 








Beckford, Worcestershire 


32 






Baldock, Hertfordshire 


119 






Cirencester 


435 






Misc. 


20 







Hickleton 60 

Barton Bendish 80 

Exeter 226 

Rand Church 12 

Nuns Field, Chester 18 

Greyfriars Court, Chester 40 

Thornhill 6 

Rhuddlan 47 

Norton Priory 149 

Austin Friars, Leicester 25 

Elstow Abbey 20 

Newark 80 

St. Oswalds Priory, Gloucester 50 

St. Giles Cathedral, Edinburgh 108 

York Minster 269 

West Mailing 236 

Stratford Langthorne Abbey 121 

Cruden Bay 36 

Linlithgow 191 

Kirk Hill 296 

Stonar, Sandwich 149 

Holy Trinity Priory, London 9 

Billingsgate 56 

Aberdeen 121 

St. Helen on the Walls 400 



Numbers of fractures identified to date are in Table 2. 
These numbers will be supplemented with examples from a 
further five cemeteries by the completion of the research. Sex 
and age of the individuals will not be discussed since they are 
irrelevant at this stage. 

Several problems with the skeletal material were encoun- 
tered. Some institutions did not know what collections they 
had, and occasionally could give only the numbers of skel- 
etons under their care and not the cemetery names. In many 
cases the bones were not clean and were therefore unsuitable 
for examination. Some collections had been divided up and 
stored in several places, and some pathological bones had 
been separated from the rest of the body. These problems 
prevented more efficient use of time when visiting the institu- 
tions concerned. 



Table 2. Number of fractures identified 





Roman 


Anglo- 


Medieval 






Saxon 


and later 


Skull 


18 


14 


24 


Humerus 


2 


2 


6 


Radius 


10 


6 


10 


Ulna 


8 


2 


7 


Femur 


4 


5 


1 


Tibia 


5 


5 


5 


Fibula 


20 


9 


13 


Multiple 


14 


6 


7 



Zagreb Paleopathology Symp 1988 



Trauma and treatment in the British Isles in the Historic Period • 229 



DISTRIBUTION OF 
CEMETERY SITES 
EXAMINED 




Figure I. Distribution ofcemetery sites examined. Note that 
some areas represent more than one site. 



Burial conditions obviously determined how complete the 
collections were. On some sites the soil pH was so low that 
much of the skeleton was eroded and some bones were not 
present for examination. This, among other factors, deter- 
mined the number of traumatic features observed. 

CLINICAL DATA 

The study of trauma in past populations is, of necessity, 
linked to diagnostic criteria in modem populations. For- 
tunately, in contrast to ancient studies of populations, mod- 
em studies of trauma are abundant in the literature. However, 
clinicians have far more data to study including, in many 
cases, a cooperative and talkative patient and clinical notes 
on which to base diagnosis and treatment. The clinician also 
has modem diagnostic t(X)ls and continuing development of 
new methods and drug therapy to aid treatment. 

In ancient populations the researcher is limited to a study, 
with whatever means available, of the dry bone evidence for 
trauma and treatment. Use of only one source of evidence for 

Zagreb Paleiipalholofiy S\mp t9ftS 



reconstructing particular aspects of society has many inher- 
ent limitations, not least a biased picture. 

The use of modem clinical data provides the opportunity to 
interpret the ancient material with a greater degree of accura- 
cy than would otherwise be possible without it. Modem trau- 
ma studies appear in five fomis: { 1 ) papers on fracture pat- 
tems in populations, e.g., Fife and Barancik 1985; (2) 
fractures of specific bones, e.g., Einarsson 1958; (3) frac- 
tures in specific age groups, e.g., children, Sharrard 1979; 
(4) complete chapters in clinical textbooks e.g. Watson- Jones 
1976; (5) specific features of fractures, e.g., Watson-Jones 
and Coltart 1982. 

Studies of fracture pattems in modem populations are in- 
valuable for workers in the field of paleopathology. This is 
particularly relevant for the subject of etiology. The different 
types of fractures observed in modem populations are usually 
correlated with specific forces acting on the bone. For exam- 
ple, an oblique fracture is usually caused by an indirect force. 
In some cases an occupational causation may be postulated 
(see Merbs 1983). 

Modem studies of fractures of specific bones are usually 
concemed with incidence, causes (by age and sex), healing 
and treatment, which are all subject areas comparable to 
ancient skeletal material. Particularly relevant is the com- 
parison of treatment and healing between ancient and modem 
populations; were ancient populations producing good re- 
sults from their fracture treatments when compared to mod- 
em healing and treatment? 

The modem literature abounds with information on types 
of fracture (cranial and postcranial), causes, healing, treat- 
ment and complications. Reference to this data is essential to 
the understanding of ancient trauma and treatment. 

However, despite being invaluable, modem clinical data 
has some limitations. Forces producing fractures have re- 
mained the same but their actual mode of production has 
altered with changing technology. The literature is filled with 
data on fractures caused by high-impact traffic accidents and 
those caused by other modem technology. These data are not 
relevant to the paleopathology of trauma. Data on healing of 
modem fractures are influenced by modem drug therapy, 
particularly antibiotics, and by modem methods of fracture 
management such as plates, pins, screws, and bone grafts. 

The age at which the fracture occurred and the sex of the 
patient are known in modem cases of fracture. In paleo- 
pathology these details arc often not definitely detemiinable. 
The age at which the fracture occurred is problematical but 
would indeed have had an effect on fracture healing. Many 
other factors must be borne in mind when interpreting the 
healing of palcopathological fractures using modern data. 
Environment, hygiene, living conditions and diet in the de- 
veloped world should be beneficial for efficient healing and 
should therefore influence healing times and the propensity 
to infection. In addition, blood vessel and nerve injuries 
associated with fractures in the palcopathological evidence 
would have significantly affected how quickly a fracture 



230 • Charlotte Roberts 



healed. In modem contexts surgical repair of vascular and 
neurological lesions would be available and thereby lessen 
healing time. 

SECONDARY DOCUMENTARY SOURCES AND ART FORMS 

In the process of using human skeletal remains from the 
Roman to late and post-Medieval periods, the availability of 
documentary sources and art forms becomes apparent, al- 
though many such sources were produced abroad and the 
texts translated into English. Sources of documentary and art 
evidence available for use are books by specific authors (in- 
cludes herbals; see Rohde 1922); medical manuscripts (e.g., 
Dawson 1934); illustrations on coins, pottery vessels and 
frescoes and in manuscripts; and sculpture. 

All these sources are secondary to the primary source. The 
validity of evidence is determined by the author's or artist's 
"clinical acumen" and by modern interpretation of docu- 
ments and artforms. Although these sources of evidence are 
invaluable for workers in this field, they should be used with 
caution. 

Authors may use words which have changed in meaning 
through time , or the words may describe something of which 
the people in the past did not know the meaning (Marwick 
1970:4). Some words used in everyday speech may actually 
be confusing when used in a historical context. Translation of 
certain words from one language to another (e.g., Latin to 
English) may prove dift'icult if there is not an exact equivalent 
of the word. Historical writing is interpretative and there 
must therefore be a subjective element therein. All authors 
and artists working in each period portray history influenced 
by their own interests. Some historians may pay particular 
attention to certain areas of interest and ignore others. As 
primary sources are often fragmentary, there is a tendency for 
conflicting conclusions (Marwick 1970:23). The very nature 
of the raw material, however, dictates the historian's function 
to convert it into the finished product by whatever means. 

Illustration and sculpture of events in the past also reflect 
the prevailing and stylistic conventions at the time of produc- 
tion. Before the advent of television, photography, film and 
printing the only way to convey information was to make a 
picture of it. The artist or sculptor may produce what he/she 
wishes to portray to observers and not the true factual record 
of the event in question. Nevertheless, this source of evidence 
is invaluable for the study of the treatment of trauma in 
antiquity and, as Herriinger ( 1970:7) said, "A good illustra- 
tion is often better than a thousand words." 

Documentary and art evidence for treatment in the past is 
abundant in the sources for each period under consideration. 
Its abundance, however, docs vary; illustrations and docu- 
mentary evidence are, of course, more prominent in the Me- 
dieval and later periods rather than in earlier times. However, 
much of the evidence in the later periods has clear connec- 
tions with earlier Greco-Roman medicine and surgery as 



displayed in early texts. A large quantity of relevant docu- 
mentary material was transferred to Britain from the east by 
travelers and invaders of the island. However, before texts 
came to Britain they were mixed with ancient Roman re- 
ligion, Mediterranean folk elements, and magico-religious 
ideas from the Far East (Grattan and Singer 1952). Texts were 
translated into English from Latin, mainly by monastic 
scribes, and made more accessible to a wider cross-section of 
society. 

In the Roman period much of the medical and surgical 
knowledge was gained from earlier Greek practice and tradi- 
tion. By the sixth century B.C. the Greeks had contact with 
Egypt and had gained much valuable information. Medical 
dogma, especially in the Anglo-Saxon period, was modified 
by Celtic elements, southern Italian influences, and Anglo- 
Saxon tradition. In the Medieval period a new influence 
came from the Arabic medical world, works which were then 
translated into Latin. 

The synthesis of different sources of information seems to 
have been a mixture of ideas from Britain and abroad. Much 
of this medical and surgical evidence can be traced to its 
original source and therefore differences between primary 
and secondary sources can be noted. It is necessary to take an 
overall view of the evidence to assess any inconsistencies 
which may arise. Nevertheless, there is much value in using 
these sources of evidence for reconstructing past treatment of 
trauma. 

The use of documentary and art evidence in the context of 
this research is undoubtedly hazardous. No one person has 
comprehensive knowledge of all the subject areas which 
need to be covered. A multidisciplinary approach to trauma 
and treatment is therefore the basis of the current research. In 
that respect, there is a need to rely on experts in other fields of 
study such as art and documentary research, to supply evi- 
dence to supplement and integrate with the rest of the data. 
While the limitations are clear and realized, the evidence will 
be used. 

ETHNOGRAPHICAL DATA 

The use of data from modem primitive societies on medical 
and surgical treatment of trauma is a further method of recon- 
structing this complex feature of past societies. Direct evi- 
dence of medicine and surgery in early man is meager, al- 
though secondary sources are abundant. It is reasonable to 
assume that modern primitive societies have retained the 
characteristics of their prehistoric predecessors in the field of 
medicine (Ackerknecht 1982:10). 

Although modem primitive societies are removed from 
ancient populations under study in terms of time and space, 
they are probably the most comparable equivalent. However, 
use of this type of data has received some criticism in the 
past. Scholars believed that information from modem primi- 
tive peoples was too different to use to explain archeological 



Zagreb Paleopathology Symp. 1988 



Trauma and treatment in the British Isles in the Historic Period • 231 



data. However, by the late l%()s. in Britain at least, more 
interest was shown in the use of ethnoarcheologicai evi- 
dence. The problem with studying archeology is the loss of 
human character in all the remains observed (Schwarz 
1978:vii). It is by studying societies of similar characteristics 
in existence today that a more humanistic and relevant inter- 
pretation of past behavior can emerge. 

The problems encountered in the use of ethnographical 
evidence are apparent. There is a bias of study of modern 
primitive societies toward hunter-gatherers (Kramer 1979:3) 
but this is perhaps a necessary and useful act before these 
.societies are encompassed into a more settled way of life with 
modem ideas and technology. The periods of time being 
studied in this particular research deal with people whose 
economy is not hunter-gathering, so care in the comparison 
and interpretation therefrom of these diverse societies is real- 
ized. 

Ethnographical studies to date have also concentrated on 
certain areas of the world, such as Africa, South America, 
and Alaska (e.g., Carroll 1972). Although these are areas 
where many societies remain uninfluenced by western ideas, 
such concentration leads to a bias in data availability. Prob- 
lems also arise when workers try to use only one society to 
explain their archeological data. A wide variety of eth- 
nographical evidence should be utilized at all times. 

Past societies in Britain, as we have seen, are very distant 
from the surviving modern primitive societies. For example, 
British researchers could not justifiably use analogies be- 
tween our contemporary industrialized society and the pre- 
historic and early historic past. But, analogs for past societies 
in Britain are provided for by historical documents which 
reduce the time and space elements. Even withstanding these 
limitations, use of this type of data should be considered 
beneficial rather than being rejected. 

ARCHEOLOGICAL DATA 

Three types of archeological data are relevant to the research: 
artifactuai, structural, and environmental (Table 3). The in- 
formation which can be derived from these data is extensive 
but can particularly reflect on relevant aspects of past so- 
cieties in relalit)n to the natural process of fracture healing, 
and the therapeutic management thereof. The environment in 
which individuals were living (both macro and microscopic), 
climate, hygiene, diet (including food available and food 
preparation), medicinal plants available, and clothing are all 
relevant to the healing process. 

The availability of this data in Britain is variable. Archeo- 
logical studies, until recently, have tended to concentrate on 
the artifactuai and structural aspects of research activities, 
primarily because these classes of data were the most abun- 
dant. It iscommonly accepted that pottery is"oneof the most 
commonly analyzed and useful kinds of artifacts available to 
archcologists" (Sharer and Ashmore 1979:306). As methods 



Table 3. Potential data sets for three types of 
archeological data 



Examples 


ARnFACTUAL 




pottery 


vessels: diet, food and 




medicinal preparation 


metal 


surgical instruments: surgery 


wood 


vessels, utensils: diet, food 




preparation 


stone 


quernstones: food 




preparation, diet 


leather 


clothing: living conditions. 




climate 


bone/ivory 


combs: hygiene 


wall plaster 


illustrations of life 


STRUCTURAL 




houses 


environment, hygiene, living 




conditions 


hospital 


care of the sick 


hearths, wells, 


climate, hygiene. 


cesspits 


environment 


latrines, sewers 


hygiene, living conditions 


bath-houses 


hygiene 


E>fVIRONMENX\L 




pollen 


all depicting environment, diet, climate 


seeds 


living conditions, diet, hygiene 


molluscs 




animal bones 




soil 




parasites 




insects 




coprolites 





of extraction of material remains, particularly environmental 
evidence, have improved over the past two decades, more 
relevant questions have been asked of the data. Diet, living 
conditions and hygiene are accepted as subjects worthy of 
study. Sir Mortimer Wheeler's words (1954) were quite ap- 
plicable, "Too often we dig up mere things unrepentantly 
forgetful that our proper aim is to dig up people." 

Work in environmental archeology has advanced in many 
areas of Britain but notably in York at the Environmental 
Archaeology Unit (O'Connor 1986). Meticulous extraction. 



Zagreb Paleopathology Symp. I9S8 



232 • Charlotte Roberts 



identification and interpretation of environmental evidence 
such as seeds, insects and animal bones has helped to extend 
archeological interpretation beyond the pottery stage. Re- 
searchers no longer end their studies at "what kind of pottery 
did they have" but can deduce "how people lived." Environ- 
mental archeology "enables archeologists to move away 
from examining the sterile remnants of ancient lives and 
envisage the communities as they actually lived" (Shackley 
1985:13). Studying one piece of evidence is no longer ac- 
cepted as the sole basis for archeological research. 

The study of archeological data in association with the 
paleopathological evidence is essential for an understanding 
of the treatment and healing of fractures. Environment, in all 
its facets, and hygiene will affect how well and quickly a 
fracture heals. 

In Britain, in general terms, archeological data is in abun- 
dance but there is often a bias in favor of particular periods of 
time (often merely because of the abundance of evidence 
available and of archeologists to deal with it) or regions of 
Britain. There is especially a tendency in environmental 
studies to produce detailed syntheses on the environmental 
conditions of one structure (see Kenward et al. 1986; Grieg 
1981 ). These studies are inevitable but useful. Disregarding 
financial constraints, however, these analyses are very labor- 
consuming. It will be some years before more regional stud- 
ies of environmental archeology will be available for use in 
such archeological research as paleopathology. In the case of 
environmental archeology at York, the process of analyzing 
organic remains is ongoing in order to extend knowledge of 
the archaic environment of York. 

The study of trauma and treatment in antiquity has by 
necessity generated many avenues of research to follow. One 
must consult many areas of evidence to gain an accurate 
picture of how well cranial and postcranial fractures were 
treated and how well they healed. This research encompasses 
the skeletal evidence of fractures and the therapeutic mea- 
sures of reduction, splinting and trepanation. But it also 
covers many other subject areas: concepts of disease and 
treatment, anesthesia, diagnostic procedures, anatomical 
knowledge, dressings, surgical instruments and herbal reme- 
dies, blood letting and hemostasis, complications of frac- 
tures, hospitals and personnel. The Roman to late and post- 
Medieval [periods were interesting eras and the wealth of 
evidence spanning 1600 years will provide abundant data for 
this research. 

Observational methods 

RECORDING OF LONG BONE AND SKULL FRACTURES: 
MACROSCOPIC 

Consultation of modem clinical data on fractures was neces- 
sary to compile a recording form adequate to describe the 



nature of the fracture with reference to modem accounts of 
fractures. Recording forms were developed for both long 
bone and skull fractures. 

Cemetery site, period of time (Roman, Anglo-Saxon and 
Medieval), location of bone, age and sex were recorded as 
basic data. The bone or anatomical part affected and side of 
body were noted so that quick reference could be made. 
Fracture position on long bones was recorded in terms of 
proximal, mid or distal third of the bone shaft. Fractures 
occurting proximally or distally to these three levels were 
described with reference to anatomical points on the bone 
(Warwick and Williams 1973). The level of fracture on the 
bone has important implications for particular neural and 
vascular complications; for example, healing of a fracture to 
the distal third of a tibia may be delayed due to a disruption in 
the blood supply to the distal fragment and a fracture to the 
midshaft of the humems may lead to radial nerve palsy. The 
radial nerve is close to the bone at this point and is therefore 
very vulnerable (Klenerman 1966). The effect of continuous 
radial nerve palsy would be paralysis of the extensor muscles 
of the wrist, thumb and fingers causing wrist drop. 

The type of fracture an individual sustains will give an 
indication of the type of force acting on the bone to produce 
the break. This feature can have implications for 

(1) interpreting occupation (e.g., Merbs 1983), warfare 
(e.g., Manchester and Elmhirst 1980), or domestic acci- 
dents; 

(2) determining how quickly the fracture healed. For ex- 
ample, oblique or spiral fractures are more stable than trans- 
verse fractures. In addition, some types of fractures are, in 
modem populations, correlated with particular types of 
accidents — a Colles fracture of the distal end of the radius, 
for example, which occurs when a person, particularly an 
elderly woman with osteoporosis, falls on an outstretched 
hand; 

(3) identifying potential complications of injuries to the 
skull; for example, a blade injury and depressed fracture 
produce different types of brain injury. Different areas of the 
skull produce contrasting complications. 

To record healing of the fracture, a general assessment was 
made of how well the bone had healed, taking into account 
many different features identifiable at the fracture site: 

SHORTENING. By Comparison with the opposite leg or arm, 
the degree of loss of length was assessed (Figure 2). This 
gave an indication of how well or how badly the fracture was 
reduced and/or splinted in the right position. 

INFECTION . Evidence of an infective process was defined by 
new bone growth and/or pitting of the bone surface around 
the fractured site with or without an associated osteomyelitic 
lesion displayed as a sinus on the bone surface (Figure 3). 
Presence or absence of infection gives an indication of the 



Zafireb Paleopathology Symp. 1988 



Trauma and treatment in the British Isles in the Historic Period • 233 





Figure 2. Oblique fracture to distal left tibia of an Anglo- 
Saxon individual (8th century a.d.) from Raunds, North- 
amptonshire. Healing has led to shortened affected limb. 



Figure 3. Radiograph of a Roman (4th century a.d.) indi- 
vidual from Baldock. Hertfordshire, showing bilateral tibial 
fractures and sinus in right tibia. 



environment in which the person was living and the type of 
fracture (simple or compound). 

DEFORMITY. Rotational or linear deformity was recorded as 
present or absent by comparing with a normal bone. More 
detailed analyses of deformity could be measured on the 
radiograph (see below). The presence of a deformity in the 
fracture once healed may suggest that the fracture was not 
treated by reduction and splinting. However, the additional 
complication of fractures of different parts of the body being 
harder to treat needs to be taken into account here. 

OSTEOARTHROSIS. Degenerative change on joint surfaces of 
long bones sustaining fractures usually (Kcurs in reaction to 
stresses placed on the joint caused by deformity of the bone 
on healing. Again, the presence or absence of this feature 
was recorded. In addition, the factor of age was also borne in 
mind. 



ALIGNMENT. The alignment of the fractured bone, once 
healed, was recorded to indicate how efficiently the fracture 
was reduced and splinted. Additional factors are as outlined 
under deformity. 

Fractures to the skull were recorded on a form modified 
from that used for long bone fractures. The bone affected and 
fracture position were noted both on the record sheet and in a 
diagram. Two types of head injury arc commonly identified 
in human remains: a blunt head injury causing a depressed 
fracture with or without comminution, or a sharp injury 
caused by a blade or other sharp object (Figures 4,5). 

Evidence of healing was noted if the wound appeared to 
have rounded and remodeled edges and the presence or ab- 
sence of endocranial involvement was recorded. This latter 
feature would have had severe implications for brain integ- 
rity. Infection, in the form of periostitic pitting of the bone 
surface around the fracture site, was documented. The pres- 
ence of an infection of a compound or open skull fracture 



Zaffreh Paleopathology Symp. 1988 



234 • Charlotte Roberts 




Figure 4. Depressed skull fracture to right parietal bone of a Roman 
individual from Hyde Street cemetery site, Winchester. Hampshire. 



Figure 5. Unhealed blade injury to left parietal 
bone of an Anglo-Saxon individual from Pewsey, 
Wiltshire. 




Figure 6. Healed trepanation associ- 
ated with a blade injury to right side of 
skull of a Roman individual from Ciren- 
cester. 



would present an opportunity for bacteria to enter the cranial 
cavity and cause endocranial infection, either abscess or 
meningitis. 

Both long bone and skull fracture forms had a section for 
commenting on possible treatment of the fracture. Many 
recorded features of long bone fractures are related to treat- 
ment, as has been seen, but only by assessing the totality of 
these features could comments be made regarding treatment. 



Head injuries in the past were sometimes treated by trepana- 
tion or surgical removal of a piece of bone from the skull. In 
some cases there is evidence of a wound to the skull associ- 
ated with a trepanation (Figure 6). Features of the trepanation 
were also recorded — operative site. type, shape and size 
(length, breadth, depth, internally and externally) of trepana- 
tion, presence of healing and any indication of infection 
present. 

Zagreb Paleopathology Symp. I9HH 



Trauma and treatment in the British Isles in the Historic Period • 235 



In all individuals, the presence or absence of cribra or- 
bitalia, porotic hyperostosis, and dental enamel hypoplasia 
was recorded to indicate the health status of the individual 
(Goodman et al. 1984). These features were important in 
terms of healing of the fracture. Fractures might heal slowly 
or not at all in an individual who has a poor diet, living in 
conditions unfavorable for healing to take place. These stress 
indicators were also noted in the individuals in the cemetery 
as a whole to compare the general health status of the popula- 
tion with that of the afl'ected individual. 

RFXORDING OF LONG BONE FRACTURES: RADIOGRAPHIC 

By necessity, the evaluation of trauma in ancient populations 
is heavily reliant on the use of radiography: macroscopic 
evidence alone is insufficient to give the information pal- 
eopathologists should seek. Radiography is perhaps one of 
the few nondestructive informative tools the paleopatholo- 
gist has. In Britain facilities for radiography are abundant but 
many workers in the field of human remains either do not 
have the resources to produce many x-rays or do not have 
access to a machine or friendly radiographer. In order to 
adequately record the fractures observed in this research it 
was necessary to ensure the availability of an x-ray machine 
and film. 

Treatment of trauma in past populations was not aided by 
radiography, which we use today to, first, diagnose whether a 
fracture was present and, second, to assess the relationship of 
the fracture fragments within the limb affected pre-, during, 
and post-treatment. Today the availability of such modem 
technology allows the paleopathological researcher to x-ray 
fractures at the stage where the break has, in most circums- 
tances, already healed. 

Following examination and recording of the long bone 
fractures in the data set, each one was x-rayed in standard 
clinical views, anteroposteriorly and mediolaterally. These 
are the minimum views which should be taken of any patho- 
logical bone because one projection may be insufficient to 
assess the abnormality. 

It was essential that these basic views were adhered to so 
that comparison with modem x-rays would be feasible; this 
was a later stage of the project. The radiographic work was 
done on a Siemens "Orbix" machine at Bradford Royal Infir- 
mary using 3M XUD film contained in a cassette fitted with 
T2 screens. 

Processing of the films was carried out using a 3M X P5()7 
90 second processing machine. The radiographic film was 
donated by an x-ray film company and the work done out of 
normal clinical working hours. The film used for this re- 
.search produces considerable image detail and was therefore 
ideal for the purposes of this study. 

Several x-rays of the smaller long bones {forearm and 
fragments of other long bones) were produced on a "Fax- 
itron" machine, a portable industrial unit within the Archae- 
ological Sciences Department at the University of Bradford. 

Zafireb Paleopathnhfiy Symp 1988 




Figure 7. Distal shaft of tibia of a Roman individual from 
Baldock, Hertfordshire (4th century a.d.): an apparently 
oblique fracture (left) is, in fact, shown to be spiral in x-ray 
(right). 



Industrex C film and manual processing made this system 
unsuitable for the research in terms of time and machine 
capacity for larger long bones. 

The skull fractures were not x-rayed as it was considered 
that little further information could be gained by observing a 
film of the injury. 

X-RAY ANALYSIS 

Each radiograph was assessed and recorded on a standard 
record sheet designed after considerable consultation of cur- 
rent radiographic analytical literature, especially Rogers 
( 1982). Features specific to the x-ray film were recorded and 
included the following: 

TYPE oi- ERACTURE. The type of fracture was not always 
clear from macroscopic observation, so an x-ray was the only 
sure way to distinguish the type of break and potential causa- 
tion (Figure 7). 



236 • Charlotte Roberts 




Figure 8. Illustration of the method of measuring angular 
deformity in a healed, fractured radius from a Medieval indi- 
vidual. 



Figure 9. Measurement of degree of apposition of fractured 
fragments. A healed, fractured tibia in an individual from a 
Roman cemetery in Winchester, Hampshire. 



FRACTURE LINE. The presence of a fracture line on the x-ray 
gave an indication of the stage of healing which the fracture, 
in relative terms, had reached. Early stages of healing will 
show a clear fracture line while a long-standing fracture 
would display a partially or fully obliterated line. 

CALLUS. The development of callus or immature bone ini- 
tially around the fracture site is evident, in the early stages of 
healing, on the x-ray as an area of bone with a "fluffy" outline 
with flecks of radio-dense material in it. This is evident with- 
in the first few weeks following the injury. As the callus 
becomes older and more mature, it becomes more uniformly 
radio-dense and opaque than the rest of the bone on the x-ray. 
As the fracture ages and the callus is calcified (from calcium 
salts from the bloodstream), the callus approaches the density 
of normal bone. The fracture line becomes obliterated and 
the trabecular pattern across the line is restored. 



A large amount of callus can indicate many things, but 
particularly the absence of inadequate immobilization after 
the fracture allowing the fragments to move and precipitate 
new bone formation. 

The rate of healing of a fracture is dependent on many 
factors, some of which have already been mentioned. The 
anatomical part of the body affected and the age of the indi- 
vidual are perhaps two of the most obvious. In most cases of 
fracture, however, the better the fracture has been treated the 
less the body has to work to repair and remodel the fractured 
area. 

DISPLACEMENT. Linear displacement of the fracture frag- 
ments was recorded by measuring the angle of displacement 
with a ruler and protractor on the x-ray film (Figure 8). 
Attempting to measure this feature on the bone itself leads to 
errors. Rotational displacement of a fracture could only be 

Zagreb Paleopathology Symp I9H8 



Trauma and treatment in the British Isles in the Historic Period • 237 




Figure \0(left). Measurement of 
amount of overlap of fracture 
fragments in a fibula fracture of 
a Medieval individual from Bil- 
lingsgate cemetery, London. 

Figure 1 1 (right). Soil in the 
medullary cavity of a fibula 
obscuring a fracture in proximal 
shaft. 




measured roughly. The relationship of the ends of the fracture 
fragments to each other was also recorded (Figure 9). Muscu- 
lar contraction at the time of injury can make reduction of 
fractures problematical, and this would have been particular- 
ly so in ancient populations. 

OVERLAP. The amount of overlap of the fracture fragments 
and degree of apposition could also be measured on the x-ray 
by direct measurement (Figured). Overlap of fragments may 
mean (for example in a tibial fracture) a shortened leg for the 
individual and difficulties with mobility. One-third to one- 
half apposition of the broken fragments in a fracture is be- 
lieved to give a good functional result in modem populations 
(Figure 10). 

X-RAY analysis: PROBLEMS 

Several problems were inherent in examining x-ray films, 
mostly generated by the fact that archeological populations 
have been buried in the ground, unlike their modem counter- 
parts. Soil in the medullary cavity of long bones made detec- 
tion of the original fracture line ditTicult (Figure 1 1) even 
though, macroscopically, there was evidence of a fracture. A 

Zagreb Paleopathology Symp. 1988 



fracture could also be misdiagnosed by the appearance of 
vascular channels in the bone shaft. Fractures of very long 
standing were often so well healed that the original type of 
fracture was not identified. 

On the x-ray in the callus there were often flecks of radio- 
dense soil particles mimicking calcified healed areas to the 
untrained eye. Alternatively, radiolucent areas around the 
fracture site could be mistaken for infective lesions, but 
the main difficulty was to determine whether the radiolucent 
area was ante or post mortem. 

Pathological fractures were often difficult to identify, es- 
pecially in the case of osteoporosis underlying the fracture. 
Osteoporosis is a very common condition today, especially in 
older women where the quality of the bone remains constant 
but the quantity decreases. This is particularly seen in ribs, 
vertebrae and the pelvis. The osteoblast and osteoclast bal- 
ance is lost and the bone is liable to break under minimal 
force. However, diagenetic factors working on skeletons in 
the ground in cemetery sites may make the bone appear to be 
osteoporotic. The main problems are whether the individual 
had osteoporosis before the fracture, after the fracture, or 
whether it developed because of bed rest (disuse osteo- 
porosis) or as a postdepositional syndrome. 



238 • Charlotte Roberts 



The final problem with x-ray analysis is the age of the 
fracture. The complete healing process, in normal circums- 
tances, takes about one year; after that time there is little 
change histologically or radiographically in the fracture ap- 
pearance. It is, therefore, difficult to ascertain at what age the 
fracture occurred in the individual unless the incident oc- 
curred just prior to death. At present, in paleopathology, ages 
of individuals with fractures are meaningless in terms of the 
timing of the fracture. 

We hope that work to be undertaken in the near future will 
give more accurate indicators of the age of fractures in an- 
cient populations. Modem, documented, clinical x-rays 
from the Institute of Orthopaedics in London will be studied. 
The x-rays will be comparable in terms of the following 
features: nonoperatively treated fractures, i.e., those treated 
with basic reduction and splinting; simple, not compound, 
fractures; all adult individuals; fractures resulting from acci- 
dents not related to modem technology. 

These x-rays will be compared with the archeological 
films, and clinical records will be consulted to ascertain the 
age of the fracture. The same recording fomi will be used to 
record the modem x-rays. The availability of clinical records 
now provides an additional potential to assess the causes of 
particular fractures in the ancient data, to know exactly how 
the fractures were treated and whether infection was present, 
and to observe the fracture on x-ray pre-, during and post- 
treatment. Modem clinical x-rays give an added time dimen- 
sion. 

Summary discussion and concluding remarks 

This paper has outlined the author's methodological ap- 
proach to trauma and treatment in the British Historic Period. 
It is fortunate for paleopathology that there has recently been 
a strong move toward this type of multidisciplinary approach 
in the interpretation of archeological sites. 

Skeletal remains from cemeteries do not represent individ- 
uals who lived cocooned in isolation from their environment. 
These people were constantly interacting with their environ- 
ment. As Calvin Wells said in 1964 (17): 

The pattern of disease or injury that affects any group of 
people is never a matter of chance. It is invariably the ex- 
pression of stresses and strains to which they are exposed, a 
response to everything in their environment and behavior. It 
reflects their genetic inheritance (which is their internal en- 
vironment) the climate in which they lived, the soil that 
gave them sustenance and the animals or plants that shared 
their homelands. It is intlucnccd by their daily occupations, 
their habits of diet, their choice of dwelling and clothes, 
their social structure, even their folklore and mythology. 
The.se words hold true over 20 years later. Archeological 
data, in whatever form, is fragmentary and reflects a sample 
of the original deposit. The nature of this deposit and its later 



interpretation, whether of human skeletal remains or pottery, 
is influenced first by the individuals who ensured its burial or 
created an environment in which it was discarded, second by 
burial conditions in the ground, third by the people who 
excavated and processed the material, and last by the person 
who examined the remains. The complete picture of particu- 
lar aspects of societies in the past is gradually lost through all 
these processes. As time proceeds from true life to a distant 
past, interpretation becomes more difficult, especially when 
only one type of evidence is being assessed. All types of 
archeological data are fragmentary but the maximum amount 
of information must be generated. Perhaps this is why re- 
searchers in human skeletal remains are beginning to realize 
the vast potential of using other sets of data to help them 
interpret data generated from human skeletal remains. This 
approach, however, is still in its infancy. 

There will always be a special place in the literature for 
unusual and isolated pathological conditions, but in the fu- 
ture there will be an increasing demand for more wider rang- 
ing analyses of human skeletal data. It will no longer be 
deemed acceptable to consider skeletons as a single entity, 
unresponsive to their surroundings. The use of modem clini- 
cal data in paleopathology will further help to broaden our 
horizons and help interpretation go further than mere diag- 
noses of cases. More epidemiological considerations in the 
future will enable paleopathologists to look upon their data 
more critically. There is much to be learned by all parties 
whether they be clinicians, paleopathologists, art historians, 
or ethnographers. There is also a move toward multi- 
disciplinary conferences (e.g., Dieppe and Rogers 1986) 
where exchange of ideas is encouraged. 

In this particular type of study it has already been noted 
that the use of multiple sets of evidence creates problems 
which can, with care, be solved. Reliance on individuals who 
are experts in their own fields to produce data relevant to the 
questions being posed is essential. However, these data can 
then be assessed by the paleopathologist and considered rele- 
vant or rejected. The limitations of each type of evidence 
being used have already been outlined and due consideration 
will be taken of these limitations in the final interpretation. 

The end results of this study will be (1) to assess the 
healing of each fracture observed, taking into consideration 
all the factors relevant to healing, and extensively consulting 
modem clinical data and x-rays; and (2) to consider the evi- 
dence for diagnosis and treatment in all periods examined, 
including all subject areas already mentioned relevant to di- 
agnosis and treatment, and to work the two sets of data 
together to interpret how well fractures in the British Historic 
Period were being treated, what techniques, equipment and 
knowledge were available, in what kind of environments did 
fractures have to heal, and whether the type of diet individu- 
als were eating was good enough for fracture healing to 
occur. 



Zagreb Pateopiithttloiiy Symp. I9fi!i 



Trauma and treatment in the British Isles in the Historic Period • 239 



There will be some areas of evidence grossly lacking and 
some will be plentiful, but it is hoped that a representative 
picture of past trauma and treatment will be produced in the 
not too distant future. 

Acknowledgements 

Due thanks go to Keith Manchester who made helpful com- 
ments throughout the paper, the many museums and arch- 
eologiai units who have allowed me access to human skeletal 
material, Tony Margel, Senior Radiographer at the Bradford 
Royal Infirmary, for producing most of the x-rays (also to a 
generous x-ray film company) and to Jean Brown, formerly 
of the Photography Department of the University of Brad- 
ford, for producing the photographs and diagrams. There are 
also many, many more people who have been helpful 
throughout this research and thanks will be given to them in 
the final thesis. 

Literature cited 

Ackcmccht, E.H. 1982. Short History of Medicine. Baltimore: 
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Arnold, C.J. 1986. Archeology and History: The Shades of Con- 
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7agrtb Paleopathology Symp I98S 



240 • Charlotte Roberts 



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Summary of audience discussion: Dr. Pahl reported that his 
dissections of Egyptian bodies suggested that the presence of a stick 
apparently splinting a fractured bone may in fact have been a splint 
on a long bone fractured post mortem, perhaps during the mum- 
mification process. He bases this on the common absence of blood 
or reactive bone changes as well as bandages. Conscc)ucnlly he 
warned that the mere presence of a splint adjacent to a fractured long 
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some therapeutic efforts in cases of long bone fracture. 



Zagreb Paleopathotogy Symp. 1988 



Paleoepidemiology of trauma in a prehistoric 
central California population 



Robert D. Junnain 



1 he challenges faced by and the personal catastrophes that 
beset prehistoric peoples sometimes fortuitously leave traces 
in their skeletons. One of the better perspectives from which 
to obtain data concerning particularly challenging events in 
the archeological past is the analysis of traumatic lesions. 

Several researchers have noted previously that evidence of 
fractures, projectile wounds, and dislocations can provide 
information concerning the incidence of accidents or inter- 
personal violence in prehistoric populations (Elliot-Smith 
and Wood-Jones 1910; Angel 1974; Edynak 1976; Lovejoy 
andHeiple 1981). 

A large and very well preserved skeletal collection from 
the prehistoric central Califomian site of Ala-329 offers fur- 
ther illumination concerning traumatic episodes in the past. 
Differential diagnosis and analysis of traumatic lesions in this 
skeletal population provide examples of severe accidents as 
well as many cases of interpersonal violence. In addition, 
comparison of reactive changes about the hip joint seen in 
this group help further clarify the distinction between trau- 
matic and congenital hip dislocation. 

Materials and methods 

Ala-329 is a large shell mound site located on the eastern 
shore of San Francisco Bay, approximately 20 miles north of 
San Jose. While now located approximately 2 '/2 miles in- 
land, the site probably once stood adjacent to the bay shore 
surrounded by saltwater marshes. Newly determined radi- 
ocarbon dates chronologically place the site between at least 
A.D. 500 and European contact (approx. a.D. 1700). 

Ala-329 is a large site with dimensions extending 133 x 
90 X 4 m high, and no doubt contains hundreds of burials. 
Excavations carried out by Stanford University and San Jo.se 
State University mostly during the 1960s exposed 20-25% 
of the mound and still removed 440 burials. The sample 
available for analysis in this study includes the 420 grave lots 
(representing a minimum of 440 individuals) excavated be- 
tween 1959 and 1968 by San Jose State University and Stan- 
ford University field classes. Of these, the most relevant 
group for the present study is the 248 aged and sexed 

Zofireh Pateopalhnlof^y Symp. 1988 



adults — 138 males and 1 10 females. Overall, the condition 
of the burials is good to excellent and. as such, this collection 
represents one of the larger and better preserved osteological 
samples in the western United States. 

Moreover, most graves were undisturbed, and careful ex- 
cavation retrieved many elements intact. Indeed, more than 
one-third of all burials could be described as "complete" 
(i.e., containing most major elements intact). Soil conditions 
at this site, apparently physically and chemically buffered by 
the large quantity of shell, afforded excellent conditions for 
preservation (see Figure 1). 

Pathological lesions were diagnosed by gross macroscopic 
examination and supported by radiographic analysis includ- 
ing standard x-ray as well as computed tomography (CT) 
scans. In most cases the diagno.ses from gross specimens and 
radiographs were corroborated through examination by an 
orthopedic surgeon. Most fractures were ascertained by the 
presence of angular deformity often accompanied by short- 
ening of the affected element. In other cases, in the absence 
of gross morphological change, a diagnosis of healed frac- 
ture could not be supported unequivocally. Indeed, detailed 
examination of more than 100 radiographs of long bones by 
the author as well as an orthopedic surgeon could not find one 
additional healed fracture. Long-standing, very well healed 
fractures with no deformity or shortening are thought by 
many researchers to be virtually impossible to detect. Some 
reports (notably. Lovejoy and Heiple 198 1 ) have relied upon 
subtle radiographic criteria to support diagnoses of most trau- 
mas. While such evidence may. in fact, be applicable to some 
specific cases, the ultimate effect will be to raise the apparent 
fracture rate in those samples to which such criteria have 
been applied, as compared to those groups (e.g., Ala-329) 
where such diagnoses are not supported. 

Results and discussion 

After dental disease and degenerative involvement ( Jurmain 
1983), trauma is the most common type of pathological le- 
sion seen in this population. In many circumstances it is not 
possible to differentiate trauma from degenerative joint dis- 

241 



242 • Robert D. Jurmain 




Table 1. Number of intact 
long bones by side 

Clavicle Left 143 
Right 148 



Radius 



Ulna 



Femur 



Tibia 



Fibula 





291 


Left 


154 


Right 


146 




300 


Left 


152 


Right 


149 




301 


Left 


147 


Right 


143 




290 


Left 


163 


Right 


150 




313 


Left 


162 


Right 


153 




315 


Left 


121 


Right 


116 




237 



Grand Total: 



2047 



Figure 1. Intact human burial at Aia-329. 



ease, especially in the hands and feet. And, as the hands and 
feet show the highest incidence of DJD, it can be reasoned 
that many of these degenerative changes result from recur- 
rent trauma. However, since precise differential diagnosis of 
remodeled lesions of hand and foot bones is not feasible, this 
study will focus upon those unambiguous changes found in 
long bones. 

For all the long bones (including the clavicle, humerus, 
radius, ulna, femur, tibia, and fibula) a total of 36 fractures 
are seen in 2047 intact long bones (Table I ), yielding a com- 
bined frequency of 1.8%. By far the most frequently frac- 
tured elements are in the forearm with 13 fractures of radii 
and l5of ulnae. Indeed, many of these fractures are probably 
"parry" fractures and a predilection for left side involvement 
is manifested (62% of radial and 60% of ulnar fractures are of 
the left side). Further, five of these fractures did not fully 
unite. Although they are seen clinically with some frequency, 
ununited fractures are not that commonly ob.served in archeo- 
logical materials. Stewart ( 1974) reports less than 10 cases 
from a total sample of several thousand individuals. From the 
large Libben collection ( > 1 300 individuals) only one further 
case of nonunion has been observed. 



Thus, five additional involved elements in a single popula- 
tion of 440 individuals deserves our consideration. The first 
case, a male 30-35 years old, has ununited fractures of both 
left forearm bones — although at different locations. The ulna 
is fractured in the distal shaft, with the marrow cavity sealed, 
but the most distal piece is missing. Comparison with the 
right ulna indicates the injury occurred approximately 50 mm 
above the distal end. The left radius is fractured farther up, 
123 mm above the distal end, and is also ununited. Again, the 
marrow cavity is completely sealed and a large reactive area 
is seen where fibrous union' would have occurred. The prox- 
imal piece, unfortunately is missing. Interestingly, in Stew- 
art's review, only one other case of such double nonunion is 
mentioned. 



1. Some authors (e.g., Ortner and Putschar 1981) prefer the term 
"pseudarthrosis" for cases of nonunion where no new joint space is 
fomicd. However, other researchers (Steinbock. pcrs. comm.) be- 
lieve "fibrous union" is a more accurate term; here, the latter termi- 
nology will be used. 

Zagreb Paleopalholog\ S\mp. 198S 



Paleoepidemiology of trauma in a prehistoric California population • 243 




Figure 2. Ununited fracture of right 
radius. Male, 35-50 years. 




!iiii|inmiii|iiiMiiM|iiir|ii 



The second case, also a male (35-50 years of age), dis- 
plays an ununited fracture of the distal right radius. Most of 
the radius is missing, but the distal piece that is present has a 
completely sealed marrow cavity. In addition, another small 
piece, representing the middle third of the diaphysis, also has 
a sealed marrow cavity (Figure 2). The right ulna is also 
fractured at approximately the same location, but shows 
good healing with a slight, angular deformity. 

The third case of nonunion is a probable female, aged 21- 
30, with an ununited fracture of the left ulna 1 1 1 mm below 
the proximal end. The marrow cavity is again sealed and 
there is evidence of fibrous union with extreme hypertrophic 
reaction particularly in the area of attachment of the pronator 
quadratus. The distal piece, however, is missing. The radius 
is uninvolved. 

The final case of nonunion is seen in the right ulna of a 
male, aged at more than 40 years at death. The lesion occurs 
73.9 mm below the proximal end, and both ends are sealed 
with fibrous union. However, the bone still appears highly 
reactive (vascularized), and there is secondary degenerative 
disease of the wrist. 

As seen, all cases of nonunion are of the forearm, as is 
consistently the pattern in other reports of this type of lesion. 
All the elements described by Stewart are also in the forearm, 
although he does mention cases involving the clavicle and 
femoral neck. Likewise, the only involved element at Libben 
is also a forearm bone (an ulna). However, it must also be 
noted that, as a result of poor recognition and diagnosis, this 
type of lesion may be considerably underrepresented in the 
paleopathological literature. Indeed, in di.scussion at the 
symposium and subsequent communication, several other 
cases of ununited fractures were noted: four from the Win- 
dover site in Florida (Dickel, pers. comm.) and two ca.ses 
from archaic populations of the Great Lakes region of North 
America (Pfeiffer 1985, pers. comm.). 

Other than the forearm, fractures in general are very rare in 
this population. Only eight other definite fractures of long 
bones are seen (two clavicles, one humerus, and five tibias). 
It must be emphasized that, as noted above, even with radi- 
ographic analysis, diagnosis of well-healed fractures is often 
impossible. 

Fracture rates are difficult to compare between popula- 
tions, as often the frequencies are not computed by individual 
elements, and even where they are, the degree of complete- 
ness of the sample is not taken into account. Among the 
better paleoepidemiological approaches to the study of frac- 
ture incidence is Lovejoy and Heiple's work with the Libben 

Zagreb Paleopathology Symp. I98S 




Figure 3. Fused right hand elements; all carpals and 2d and 
3d metacarpals. Female, 39-44 years. 



population. In order to control foreffect of preservation, only 
intact long bones were included and carefully tabulated. A 
similar methodology is used here. The overall fracture inci- 
dence at Libben was 72/2383 (3.0%) compared to 36/2047 
(1.8%), that is, only about half as high in this study. In 
addition to the clear quantitative difference in frequency, the 
pattern of involvement also varies dramatically. At Libben, 
the most frequently fractured element was the clavicle, in- 
volved in 15/260 cases (5.8%). At Ala-329, however, only 
two definite clavicular fractures are found in 291 intact ele- 
ments (less than 1%). Certainly, in modem groups, most 
clavicular fractures result from severe falls (or auto acci- 
dents). The frequency of bad falls at Ala-329 thus appears to 
have been lower than at Libben. Indeed, Lovejoy and Heiple 
(1981) state that from modem U.S. data the clavicle is the 
most fractured long bone. 

A particularly dramatic case at Ala-329 that did result from 
a severe fall is a 39-44-year-old female who had an apparent 
fracture to the distal right ulna (or Allen's fracture) that also 
severely traumatized the hand. Indeed, all the carpals plus 
the 2d and 3d metacarpals are fused into a solid block (Figure 
3). In addition, the left arm is also broken (distal left radius), 
all perhaps as a result of one very serious fall. 

Therefore, it would seem a different fracture pattem is 
indicated at Ala-329 compared to that at Libben. At Ala-329, 
severe falls were not the single primary cause of fracture. The 
relative infrequency of Colles' and Allen's fractures, seen in 
only II cases (5 Colics'. 6 Allen's), further suggests this. 
Another possible explanation for the lower frequency of frac- 
tures seen in the Califomian population could be demograph- 
ic. Lovejoy and Heiple (1981) make the explicit point that 
fracture risk is directly linked to longevity. And, indeed, 
older individuals in both samples have more healed fractures. 



244 • Robert D. Jurmain 



TabLH 2. Fracture incidence by element 





Ala-329 


Libben 


Danish 


Great 
Lakes 




N(%) 


NCTc) 


N(7o) 


N(%\ 


Clavicle 


2/291 (0.7) 


15/260 (5.7) 


5/386 (1.3) 


2/66 (3.0) 


Humerus 


1/300 (0.3) 


3/450 (0.7) 


1/703 (0.1) 


3/140 (2.1) 


Radius 


13/301 (4.3) 


20/369 (5.4) 


9/608 (1.5) 


4/103 (3.9) 


Ulna 


15/290 (5.2) 


11/351 (3.1) 


13/607 (2.1) 


3/124 (2.4) 


Femur 


0/313 (0.0) 


9/347 (2.6) 


0/998 (0.0) 


1/112 (0.9) 


Tibia 


5/315 (1.6) 


5/349 (1.4) 


6/852 (0.7) 


2/82 (2.4) 


Fibula 


0/237 (0.0) 


9/257 (3.5) 


2/364 (0.6) 


1/?- 



Sources: Libben, Lovejoy and Heiple 1981; Danish, Bennike 1985; 
Great Lakes, Pfeiffer 1985 (pers. comm.). 



The average age for individuals with ulnar fractures is 41 
years at Libben and 39 years at Ala-329. For radial involve- 
ment the average age is 42 years at Libben and 4 1 at Ala-329. 

It could be asked, then, if the Libben sample represents an 
older population. Here also, no clear differences appear, as 
the demographic profiles are generally quite similar. At Lib- 
ben 26% of adults lived past age 40, while at Ala-329 28% of 
adults survived into the fifth decade. 

It can be concluded, then, that age differences in these two 
populations do not adequately account for the differences in 
fracture incidence. Further systematic and thus comparative 
data on fracture frequency are available from a few other 
studies. In particular, Bennike (1985) has carefully com- 
puted incidence for a Danish skeletal series (Neolithic- 
Medieval) by element, and Pfeiffer (pers. comm.) has re- 
cently done likewise on archaic North American skeletal 
samples from the Great Lakes region of the U.S. and Canada. 
The results of these two studies as well as from the Libben 
series are compared with fracture incidence at Ala-329 in 
Table 2. 

The frequency of forearm midshaft injuries suggests inter- 
personal violence (i.e., parry fractures), which is further 
indicated by the predilection mentioned earlier for left side 
involvement. Arguing against intergroup fighting is the simi- 
lar incidence of female involvement in the forearm as that 
seen among males (13 male, 14 female). This observation 
does not of course preclude violence directed at women with- 
in the group. 

However, there is more direct evidence of interpersonal 
violence in this group: nine individuals have embedded pro- 
jectile f)oints, and a tenth has evidence of a healed wound 
also probably from a projectile. 

The first case is the healed wound, seen in the distal left 
femur of an adult male, 20-30 years of age. The lesion is an 




Figure 4. Radiograph, distal left femur showing 
healed lesion in center, superior to medial con- 
dyle. Male, 20-30 years. 



ovoid defect superior to the medial femoral condyle and 
showing hypertrophic formation both ventrally (entrance) 
and dorsally (exit), indicating the wound completely pierced 
the bone. On x-ray, the lesion appears quite "nonphysiologi- 
cal" in origin, given the nonregular shape of the canal (Figure 
4). Obviously, considerable healing occurred following the 
injury. Interestingly, at the time of excavation, spent projec- 
tiles were found in the mouth of this individual. 

The second case is a young adult female aged 19-21 years 
with a large obsidian projectile point embedded in the ventral 
body of the 5th lumbar vertebra (Figure 5). X-ray and CT 
scan analysis revealed no remodeling (healing) around the 
wound (Figure 6). Indeed, it would not be expected that this 
victim survived the injury, as soft tissue trauma due to hemor- 
rhaging and intra-abdominal infection would have been un- 
avoidable. 

The next two cases are also vertebral wounds, but both of 
these are from the back. A teenager (14-18 years old) of 
indeterminate sex also has an obsidian point in the 5th lumbar 
vertebra embedded in the right dorsoinferior portion of its 
body. Under magnification a "nick" is also apparent along the 
lateral edge of the right pars interarticularis. Potential in- 
volvement of the right first sacral nerve root is thus sug- 
gested. No e